Quality health plans & benefits Healthier living Financial well-being Intelligent solutions. Here s to your health Aetna Medicare Advantage plan

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Here s to your health Aetna Medicare Advantage plan

2 Our plan offers you what you need to stay healthy. Learn more.

3 You ve worked hard. Now let the Aetna Medicare Advantage SM Plan work hard for you. Dear UAW Trust Member, The UAW Retiree Medical Benefits Trust (the Trust ) provides health care benefits for UAW Trust members and their dependents. The Trust, in partnership with Aetna, is pleased to offer you the Aetna Medicare Advantage Preferred Provider Organization (PPO) with Extended Service Area (ESA) Plan. Through the Trust, you have a special opportunity to enroll in a health plan that offers coverage with additional benefits not included in your current plan and programs to help improve health and wellness all at a lower cost. This Medicare Advantage plan is designed to do more to help meet your coverage needs. An Aetna Medicare Advantage PPO ESA Plan could offer you the most value With the Aetna Medicare Advantage Plan, you will have coverage for your Original Medicare Parts A and B hospital and medical benefits, plus you will have additional benefits not covered by Medicare. You are able to use doctors and hospitals in or out of our Aetna Medicare network, as long as they are willing to accept the Aetna plan and are eligible to receive payment from Original Medicare. It s your choice! The benefits and cost sharing will be the same. Here are some of the advantages of the Aetna Medicare Advantage plan you can enjoy for 2013: - For all members who enroll in the Aetna Medicare Advantage plan for 2013, the Trust will waive your monthly contribution for the entire year! - Many preventive care services available at no cost to you - Personal lifestyle coaching to help you reduce stress, lose weight or quit smoking - 24/7 access to our dedicated Nurse Case Managers. Our Nurse Case Managers are skilled professionals who are there to help you manage your health, whether you have an acute illness or multiple chronic conditions - Easy-to-use online Personal Health Record that lets you organize your health information and access tools to help you make informed health care decisions GRP_11_ UAW

4 See how the Aetna Medicare Advantage plan compares to the Traditional plan: Please note that the chart shows 2013 plan costs which have a slightly higher monthly contribution, as well as increases in plan deductibles, out-of-pocket maximums and prescription drug copays. Member Cost Share (in-network) Monthly Contribution for 2013 Office Visits Trust Plan Deductible Out-of-Pocket Max Emergency Room Copay Urgent Care Copay Prescription Drug Copays 1 (retail/mail order) Aetna Medicare Advantage (MA) PPO 1 $0 / month (for 2013 only) $25 copay per visit, Part B Deductible does not apply BCBS Traditional Care Network (TCN) 1 $192 / year ($16 / month) Covered by Original Medicare at 80%, after Part B Deductible is met Savings When Enrolled in MA PPO $192 / year ($16 / month) Difference: $25 vs. 20% $215 $325 $110 savings $550 $650 $100 savings $50 per visit $100 per visit $50 savings per visit $25 per visit $50 per visit $25 savings per visit Tier 1: $11/$22 Tier 2: $33/$66 Tier 3: $88/$176 Tier 1: $11/$22 Tier 2: $33/$66 Tier 3: $88/$176 Same Total savings per year of up to $402 per member. 2 1 Cost share for Total savings for monthly contribution, out-of-pocket maximum and deductible GRP_11_ UAW

5 Enrolling is simple. To enroll, call Retiree Health Care Connect (RHCC) on or after November 1, Generally, plan changes are effective the first day of the second month following the date of the request. Please call your applicable number below. GM / Chrysler Trust members: Ford Trust members: Aetna has enclosed specific plan information in this packet which includes the following: - Aetna Medicare Advantage Plan and program information - Benefits At-A-Glance - Aetna Health and Wellness discounts and programs - Helpful tools - Plan details It is easy to find out more. Make sure you review the Important things to consider summary on the next page. To speak with a helpful plan specialist, call (TDD: 711); 8 a.m. to 8 p.m. ET., 7 days a week. Visit and select Find a Doctor to find out if your providers are in the Aetna Medicare network. You may also find out if your doctor is participating in the Aetna Medicare network by calling (TDD: 711); 8 a.m. to 8 p.m. ET., 7 days a week. If your doctor is not in our network, please check with your doctor to find out if they will accept the Aetna Medicare PPO ESA Plan prior to obtaining services. To find out about our open houses, plan details, resources available to you, and more, go to the Aetna web site for UAW Trust members at: Wishing you the best of health, The Aetna Medicare Team GRP_11_ UAW

6 Important things to consider: The Aetna Medicare coverage offered by the UAW Retiree Medical Benefits Trust is available only to eligible retirees and dependents. You will not automatically be enrolled in the Aetna Medicare Advantage Plan. You will remain on your current plan unless you choose to switch plans. To be eligible for the Aetna Medicare Advantage Plan, you must be enrolled in Medicare Part A and Part B. You must continue to pay your Part B premium and Part A premium, if applicable. Refer to information provided by the UAW Retiree Medical Benefits Trust for other important eligibility details. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. A Medicare Advantage organization with a Medicare contract. Benefits, premium and/or co-payments/co-insurance may change on January 1, Plans are offered by Aetna Health Inc., Aetna Health of California Inc., and/or Aetna Life Insurance Company (Aetna). 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 and are subject to change each year Aetna Inc. FPO FSC Logo Here GRP_11_ UAW

7 B You have our ear. In the past 40 years, we ve worked to bring retirees strong, affordable health plans. Backed by a tradition that has helped protect the health and well-being of our retiree, by listening, always. Applying our best minds and resources to meet your needs. So your health plan has an unmistakable voice. Yours.

8 Why Aetna Medicare Advantage Preferred Provider Organization (PPO) with an Extended Service Area (ESA)? The Aetna Medicare SM (PPO) plan with an Extended Service Area (ESA) offers services and programs beyond Original Medicare and includes special programs only available to Aetna members. And, unlike a traditional PPO, you can use in-network or out-of-network providers, at the in-network cost sharing amount. This gives you added flexibility when it comes to your care B (9/11)

9 Aetna Medicare Plan (PPO) with an Extended Service Area (ESA) Plan details: You can use providers who are in or out of the plan s nationwide network. An out-ofnetwork provider must be eligible to receive Medicare payment and willing to accept the PPO ESA plan. What s special: Our Care Management program is designed to help you manage health conditions such as hypertension. Freedom to use providers in and out of network as long as they are eligible for Medicare payment and agree to accept your PPO ESA plan. Selecting a primary care physician (PCP) is not required, but we do encourage you to select one. A PCP is often the only doctor who has a complete picture of your health. If you do not have a PCP, you may find one within our network. If your PCP is not in our network, you can encourage him/ her to join Aetna. Access to the National Medical Excellence Program, a select network of respected doctors and facilities designed to help those with a complex illness or injury receive the most appropriate care. Preventive benefits beyond Original Medicare at no additional cost. What you should know: You must be enrolled in Medicare Part A and/or B and continue to pay your Part B premium and Part A premium. You must live in the plan service area offered by your former employer/union/trust. You ll enjoy limits to your out-of-pocket plan costs. If you use a provider that does not participate in the plan s network, the provider must be licensed, eligible to receive Medicare payment and willing to accept the plan. For complete information, please refer to your plan documents.

10 What benefits do I get as a member? With the Aetna Medicare Plan (PPO) with an Extended Service Area (ESA), you may have access to many or more of the same great benefits that you may have now. Check it out. Aetna Medicare Advantage Benefits at-a-glance 1 PPO Plan with an Extended Service Area No network restrictions. Freedom to use any licensed provider that is eligible for Medicare and willing to accept the PPO ESA plan * No referrals needed for specialists Includes all Medicare Parts A and B medical benefits, plus additional benefits not covered by Original Medicare Limitations on your out-of-pocket costs Coverage for unlimited inpatient hospital days Preventive benefits beyond Original Medicare at no additional cost Healthy lifestyle coaching at no extra cost Online Personal Health Record that helps you make informed health care decisions, at no extra cost Special program designed to help you manage your health conditions Coverage for emergency or urgently needed medical treatments worldwide Access to Aetna Navigator claim searches Access to our 24-hour Informed Health Line Aetna Extras SM at no extra cost: discounts on health-related products and services 1 While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on more than 5,000 topics. Contact your doctor first with any questions or concerns regarding your health care needs. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professionals. * You will pay the low in-network cost share amount whether you use providers in- or outof-network. If you use an out-of-network provider, they must be willing to accept your PPO ESA plan and be eligible to receive Medicare payment.

11 Aetna Extras SM As an Aetna Medicare plan member, you get access to programs and services, tools and information all extras to help protect your health and health care dollars. Health and wellness discounts 1 Aetna Vision SM discount program Aetna Hearing SM discount program Aetna Fitness SM discount program Save on routine eye exams and select items and services, including LASIK surgery. Save on hearing aids, comprehensive hearing tests and hearing-aid services from licensed professionals in certain areas. Access preferred rates on gym memberships through the GlobalFit network as well as discounts on at-home weight-loss programs, home fitness options and one-onone health coaching services. Aetna Natural Products and Services SM discount program Aetna Weight Management SM discount program The Aetna Book SM discount program Offers reduced rates on acupuncture, chiropractic care, massage therapy and dietetic counseling through the ChooseHealthy program.* Get discounts on over-thecounter vitamins, herbal and nutritional supplements and natural products. Through Vital Health Network, you can receive a discount on online consultations and alternative remedies provided by medical doctors for a variety of conditions. Save on some of today s most popular weight loss programs, diet and meal plans.** Access discounts on books and other items purchased from the American Cancer Society Bookstore, the MayoClinic.com Bookstore and, for yoga-related titles, Pranamaya.com.

12 Discounts on other products and memberships including: MEM-X vocal memory aids, reminding you at a precise data and time of whatever it is you d like to do, from making a phone call to taking a medication. Sonic toothbrushes and water-jet flossers from Waterpik. Epic Dental products, such as gum toothpastes and mouth rinses. Aging with Grace, LLC (AWG) a national assistance program for members and their caregivers. AWG can help create a senior care plan by educating, coordinating and facilitating through the many options available, including access to accredited VA claims agents for veterans. Aetna Medicare members receive an exclusive discount on the annual AWG membership fee. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Discounts do not apply to some discount vendor plans, programs, food and/or products. Aetna may receive a percentage of the fee you pay to a discount vendor. Information is believed to be accurate as of the production date; however it is subject to change. 1 The products and services described are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Aetna Medicare Plan grievance process. * The ChooseHealthy program is made available through American Specialty Health Networks, Inc. (ASH Networks) and Healthyroads, Inc., subsidiaries of American Specialty Health Incorporated (ASH). ChooseHealthy is a federally registered trademark of ASH and used with permission herein. **Discounts do not apply to some plans, programs, food and/or products.

13 Health and wellness programs 1 Aetna Health Connections SM disease management program Annual preventive reminders Women s health reminders Nurse case managers Informed Health Line 1 Healthy lifestyle coaching Offers educational materials and resources designed to help you live better with conditions and health issues such as diabetes, asthma or arthritis. Can help you remember to get important vaccinations, like flu shots, and colorectal cancer screenings. Receive timely screening reminders for breast and cervical cancers. Get personalized support for chronic and/or serious health conditions from specially trained medical professionals. Talk directly with our experienced registered nurses about thousands of health topics using our 24-hour toll-free number. Speak to a licensed professional by phone to develop a specific program based on your health needs; learn how to manage weight and/or stress, quit smoking and maintain good health. National Medical Excellence Program Patient safety through care considerations Offers access to our national Institutes of Excellence Transplant Network for transplants and transplantrelated services. It includes medical management through the recovery period. Case management is also provided for members with rare or complex conditions requiring specialized treatment. Get timely alerts and additional reminders that can help you stay healthy. These messages may warn you of potentially dangerous drug combinations, or remind you of important tests and screenings. 1 While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on more than 5,000 topics. Contact your doctor first with any questions or concerns regarding your health care needs. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professionals.

14 Tools Personal health record Aetna Navigator Aetna Intelihealth Health risk assessment tools DocFind Keep track of health information online and get tips on alternative therapies. View claims, print a temporary ID card and more, online. View educational illustrations and interactive online features to learn about health care. Assess your health care needs; manage health conditions. Locate physicians, hospitals, pharmacies and other participating health care professionals with this online search tool. Search by name, zip code, city, state, specialty and/or hospital affiliation. Locate a network provider or hospital near you by using DocFind, our online provider directory at and click on Find a Doctor or call the number listed under Contact Us on the Aetna welcome page of this booklet. If you live outside of our plan service area, you can locate Medicare providers by visiting,

15 What materials should I expect as a member? See the chart below for what you can expect once you are enrolled. What is it? Plan confirmation letter A letter informing you that we have confirmed with the Centers for Medicare & Medicaid Services (CMS) that you are approved to become a member of our plan. Aetna Medicare identification (ID) card This is the card you show to providers prior to receiving services. If you need to obtain services before you receive your ID card, present the Plan Confirmation Letter or Enrollment Application to your provider as documentation that you have elected our plan. How will I receive? U.S. Mail When should I expect it? After enrollment U.S. Mail Within 10 days after CMS approval Health risk survey We will call to ask general questions regarding your health. You can also complete the survey on paper and mail it back. Plan documents You will also receive several plan documents to help you understand and use your plan. They include the Evidence of Coverage, a Schedule of Copayments and a directory (if you live within our PPO network service area). If you are enrolled in a plan with Medicare Prescription Drug coverage, you will also receive a prescription drug formulary. Several attempts by phone, then U.S. Mail U.S. Mail After enrollment Within 10 days of confirmed enrollment, or by the last day of the month prior to the enrollment effective date, whichever comes first

16 The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. A Medicare Advantage organization with a Medicare contract. Health insurance plans are offered by Aetna Life Insurance Company. Plans contain exclusions and limitations. You must be entitled to Medicare Part A and Part B. You must continue to pay your Part B premium and Part A, if applicable unless you are enrolled in an Aetna Medicare Advantage Part B only plan and reside in the service area of the plan. Benefits, limitations, service areas and premiums are subject to change on January 1 of each year. Member precertification, or prior approval of coverage, is recommended for certain services. Providers must be licensed, eligible to receive payment under the federal Medicare program and willing to accept your PPO plan. This material is for informational purposes only. 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 and are subject to change. Aetna does not provide care or guarantee access to health services. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Discount programs provide access to discounted prices and are not insured benefits. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Translation of this material into another language may be available. For assistance, please call Member Services at the number listed on the cover letter under Contact Us. Puede estar disponible la traducción de este material en otro idioma. Para asistencia, por favor llame a Servicio al Cliente al teléfono indicado al inicio de este documento bajo Contáctenos. GRP_11_ Aetna Inc.

17 UAW Retiree Medical Benefits Trust Aetna Medicare SM Plan (PPO) Medicare ESA PPO Plan Benefits, Value Added Services are effective January 1, 2013 through December 31, 2013 Arizona, Connecticut, Delaware, Georgia, Maryland, New York, Ohio, Oklahoma, Pennsylvania, Texas PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES Deductible (per calendar year) Network Providers $215 Deductible Out-of-Network Providers $215 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Deductible waived for: Routine Physicals, Routine Mammograms, Routine Hearing Exam, Routine Colorectal Screening, Routine Prostate Screening, Bone Mass Measurement, Immunizations, Routine GYN, Routine Eye Exam, ***Additional Medicare Preventive Care Services, Diabetic Supplies, Physician and Specialist Office Visits, Diagnostic Laboratory, Renal Dialysis, Chiropractic Care, Durable Medical Equipment, Prosthetics, Inpatient Mental Health and Substance Abuse Facility, Outpatient Mental Health and Substance Abuse, Home Health Care, Emergency Room, Emergency Transport Services and Urgently Needed Care. Deductible is NOT applicable to Hearing Aid Reimbursement that is available on your plan. Member Coinsurance 10% Applies to all expenses unless otherwise stated. Annual Primary Out-of-Pocket $550 Amount (includes deductible) 10% $550 Combined Annual Maximum Out-of- Pocket Amount (Plan Level / includes deductible) $3,000 $3,000 Expenses that apply to Annual In-Network and Out-of-Network Primary Out-of Pocket Amount: Outpatient Rehabilitation, Diagnostic X-ray, Complex Radiology, Dialysis, Allergy Testing and Treatment, Inpatient and Outpatient Hospital (Including Surgery), Non-Emergency Ambulance, Skilled Nursing Facility, Medicare Part B Prescription Drugs, Chemotherapy and Radiation Treatments. Annual Maximum Out-of-pocket Limit amount applies to all medical expenses EXCEPT Hearing Aid Reimbursement that is available on your plan. Primary Care Physician Selection Certification Requirements Optional Not Applicable There is not a requirement for member pre-certification. If a member fails to obtain pre-certification they will not be denied services or will any penalty amount be applied. However, pre-certification is requested on certain services including inpatient hospital care, inpatient mental health and substance abuse, skilled nursing facility, home health care and some durable medical equipment. Referral Requirement PREVENTIVE CARE Routine Physicals (Yearly Wellness Exams) / Immunizations None Covered 100% None Covered 100% One annual exam. Pneumococcal, Flu, Hepatitis B covered 100% Routine GYN Exams (Cervical and Vaginal Cancer Screenings) One routine GYN visit and pap smear every 12 months Covered 100% Covered 100% M0001_7A_70652 Page 1

18 UAW Retiree Medical Benefits Trust Aetna Medicare SM Plan (PPO) Medicare ESA PPO Plan Benefits, Value Added Services are effective January 1, 2013 through December 31, 2013 Arizona, Connecticut, Delaware, Georgia, Maryland, New York, Ohio, Oklahoma, Pennsylvania, Texas PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Routine Mammograms Covered 100% Covered 100% (Breast Cancer Screening) One annual mammogram for members age 40 and over Routine Prostate Cancer Screening Covered 100% Covered 100% Exam For covered males age 40 and over Routine Colorectal Cancer Screening Covered 100% Covered 100% For all members age 50 and over. Digital Rectal Exam Routine Bone Mass Measurement Covered 100% Covered 100% Covered 100% Covered 100% Medical Nutrition Therapy Additional Medicare Preventive Services*** Routine Eye Exams One(1) annual exam Diagnostic Eye Exam Routine Hearing Exams One(1) annual exam Diagnostic Hearing Exams Covered 100% Covered 100% Covered 100% Covered 100% $25 Copay $25 Copay $25 Copay $25 Copay $25 Copay $25 Copay Covered 100% Covered 100% PHYSICIAN SERVICES Primary Care Physician Visits $25 copay $25 copay Primary Care Physician Visits (after hours) $25 copay $25 copay Includes services of an internist, general physician, family practitioner for routine care as well as diagnosis and treatment of an illness or injury and in-office surgery. Physician Specialist Visits $25 copay $25 copay Gynecology Visits $25 copay $25 copay Office Visits for Surgery $25 copay $25 copay Allergy Testing/Treatment Office Visits for Allergy Testing/Treatment DIAGNOSTIC PROCEDURES Outpatient Diagnostic Laboratory and X-Ray 10%, after deductible $25 copay Covered 100% 10%, after deductible $25 copay Covered 100% M0001_7A_70652 Page 2

19 UAW Retiree Medical Benefits Trust Aetna Medicare SM Plan (PPO) Medicare ESA PPO Plan Benefits, Value Added Services are effective January 1, 2013 through December 31, 2013 Arizona, Connecticut, Delaware, Georgia, Maryland, New York, Ohio, Oklahoma, Pennsylvania, Texas PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Outpatient Diagnostic X-Ray 10%, after deductible 10%, after deductible Complex Imaging (PET Scans, CAT Scans, MRI's) EMERGENCY MEDICAL CARE Urgently Needed Care Emergency Room; Worldwide (waived if admitted) Emergency Transport Services 10%, after deductible $25 copay $50 copay 10%, no deductible 10%, after deductible $25 copay $50 copay 10%, no deductible HOSPITAL CARE Inpatient Hospital Care 10%, after deductible 10%, after deductible The member cost sharing applies to covered benefits incurred during a member's inpatient stay Outpatient Hospital Expenses (including surgery) 10%, after deductible 10%, after deductible The member cost sharing applies to covered benefits incurred during a member's outpatient visit MENTAL HEALTH SERVICES Inpatient Mental Health Care Covered 100%, no deductible Covered 100%, no deductible The member cost sharing applies to covered benefits incurred during a member's inpatient stay 190 days lifetime maximum Maximum are a combined limit for preferred and non-preferred services. Outpatient Mental Health Care Covered 100%, no deductible Covered 100%, no deductible The member cost sharing applies to covered benefits incurred during a member's outpatient visit ALCOHOL/DRUG ABUSE SERVICES Inpatient Substance Abuse (Detox and Rehab) Covered 100%, no deductible Covered 100%, no deductible The member cost sharing applies to covered benefits incurred during a member's inpatient stay Maximums are a combined limit for preferred and non-preferred services. Outpatient Substance Abuse (Detox and Rehab) Covered 100%, no deductible Covered 100%, no deductible The member cost sharing applies to covered benefits incurred during a member's outpatient visit OTHER SERVICES Skilled Nursing Facility 10%, after deductible 10%, after deductible Limited to 100 days per Medicare benefit period. The member cost sharing applies to covered benefits incurred during a member's inpatient stay Home Health Agency Care Hospice Care Covered 100% Covered by Medicare at a Covered 100% Covered by Medicare at a Medicare certified hospice Medicare certified hospice M0001_7A_70652 Page 3

20 UAW Retiree Medical Benefits Trust Aetna Medicare SM Plan (PPO) Medicare ESA PPO Plan Benefits, Value Added Services are effective January 1, 2013 through December 31, 2013 Arizona, Connecticut, Delaware, Georgia, Maryland, New York, Ohio, Oklahoma, Pennsylvania, Texas PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Outpatient Rehabilitation Services 10% after deductible 10% after deductible (Includes speech, physical and occupational therapy) Chiropractic Services $20 Copay $20 Copay For manipulation of the spine to the extent covered by Medicare Durable Medical Equipment/ Covered 100% Covered 100% Prosthetic Devices Wigs Compression Stockings (must be obtained from a Medicare Supplier) Podiatry Services Limited to Medicare covered benefits only Diabetic Supplies Outpatient Chemotherapy Covered 100% 10%, after deductible Covered 100% 10%, after deductible Outpatient Radiation Covered 100% up to a $250 annual maximum Covered 100% $25 copay 10%, after deductible Covered 100% up to a $250 annual maximum Covered 100% $25 copay 10%, after deductible Outpatient Dialysis Treatments Medicare Part B Prescription Drugs Vision Eyewear Allowance Hearing Aid Reimbursement Statement of Satisfaction Form required 10% no deductible 10% after deductible Lens Discounts $2,000 maximum, once every 36 months, for up to two standard or digital hearing aids 10% no deductible 10% after deductible Lens Discounts $2,000 maximum, once every 36 months, for up to two standard or digital hearing aids Coaching One phone call per week MA only Included Not covered *** Additional Medicare Preventive Services include ultrasound screening for abdominal aortic aneurysm (AAA), alcohol misuse screening and counseling, cardiovascular behavioral therapy, depression screening, cardiovascular disease screening, diabetes screening tests, diabetes self-management training (DSMT), glaucoma screening, obesity screening and counseling, smoking & tobacco use cessation counseling, HIV screening and annual wellness visit. Benefits, limitations, service areas and premiums are subject to change on January 1 of each year. Members must be entitled to Medicare Part A and continue to pay the Part B premium and Part A, if applicable. M0001_7A_70652 Page 4

21 UAW Retiree Medical Benefits Trust Aetna Medicare SM Plan (PPO) Medicare ESA PPO Plan Benefits, Value Added Services are effective January 1, 2013 through December 31, 2013 Arizona, Connecticut, Delaware, Georgia, Maryland, New York, Ohio, Oklahoma, Pennsylvania, Texas PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY This material is for informational purposes only. 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 and are subject to change. Providers are independent contractors and are not agents of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Aetna does not provide care or guarantee access to health services. In case of emergency, members should call 911 or the local emergency hotline, or go directly to an emergency care facility. The following is a partial listing of exclusions and limitations under the Aetna Medicare SM Plan (PPO): Services that are not medically necessary or covered under the Original Medicare Program; Plastic or cosmetic surgery unless medically necessary; Custodial care; Experimental procedures or treatments beyond Original Medicare limits; Routine foot care that is not medically necessary Outpatient Prescription Drugs except those covered under Original Medicare Part B. Precertification, or prior approval of coverage is requested for certain services. Providers must be licensed and eligible to receive payment under the federal Medicare program. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject to change. In the event of a conflict or inconsistency between this material and plan documents, the terms of the plan document shall govern. Discount programs provide access to discounted prices and are not insured benefits. The member is responsible for the full cost of the discounted services. Health benefits and health insurance plans contain exclusions and limitations. Health Benefits and Health Insurance plans are offered by Aetna Health Inc., Aetna Health of California Inc., and/or Aetna Life Insurance Company (Aetna). A Medicare Advantage organization with a Medicare contract. A Medicare approved Part D sponsor. This document may be available in a different format or language. For assistance, please call Member Services at (TTY/TDD: ). Calls to this number are free. Hours of operation: 7 days per week, 8am till 8pm. Este documento podría estar disponsible en diferentes formatos o idiomas. Para ayuda, por favor llame a Servicios al Miembro al (TTY/TDD: ). Las llamadas a este número son gratuitas. Horario de atención: los 7 días de la semana, de 8 a.m. a 8 p.m. MA and PDP For more information about Aetna plans, refer to Aetna Medicare ***This is the end of this plan benefit summary*** M0001_7A_70652 Page 5

22 E Disclosures, Exclusions/ Limitations, and Disclaimers

23 Important Disclosure Information Aetna MedicareSM Plan (HMO) and Aetna MedicareSM Plan (PPO) Note: Medicare Advantage plan requirements govern and supersede any state or general disclosures contained within. Plan Benefits Covered services include most types of treatment provided by primary care physicians, specialists and hospitals. However, the health plan does exclude and/or include limits on coverage for some services, including but not limited to, cosmetic surgery and experimental procedures. In addition, in order to be covered, all services, including the location (type of facility), duration and costs of services, must be medically necessary as defined below and as determined by Aetna. The information that follows provides general information regarding Aetna health plans. For a complete description of the benefits available to you, including procedures to follow, exclusions and limitations, refer to your specific plan documents, which may include the Summary of Benefits, Evidence of Coverage and any applicable riders and amendments to your plan. Member Cost Sharing Cost sharing refers to the portion of medical services that you pay out of your own pocket. Refer to your plan documents to see which of the following cost-sharing provisions apply to your plan: Copay This may be a flat fee that you pay directly to the health care provider at the time of service. Coinsurance This is a percentage of the fees that you must pay toward the cost of some covered medical expenses. Your health care provider will bill you for this amount. Calendar Year Deductible The amount of covered medical expenses you pay each calendar year before benefits are paid. There is a calendar-year deductible that applies to each person. Inpatient Hospital Deductible The amount of covered inpatient hospital expenses you pay for each hospital confinement before benefits are paid. This deductible is in addition to any other copayments or deductibles under your plan. Emergency Room Deductible The amount of covered hospital emergency room expenses you pay each year before benefits are paid. A separate hospital emergency room deductible applies to each visit by a person to a hospital emergency room unless the person is admitted to the hospital as an inpatient within 24 hours after a visit to a hospital emergency room. M0001_M_PE_MM_90810 (09/2009)

24 Your Primary Care Physician Check your plan documents to see if your plan requires you to select a primary care physician (PCP). If a PCP is required, you must choose a doctor from the Aetna network. You can look up network doctors in a printed Aetna Physician Directory, or visit our DocFind directory at If you do not have Internet access and would like a printed directory, please contact Member Services at the toll-free number on your ID card and request a copy. You may choose a different PCP for each member of your family. When you enroll, indicate the name of the PCP you have chosen on your enrollment form. Or, call Member Services after you enroll to tell us your selection. The name of your PCP will appear on your Aetna ID card. You may change your selected PCP at any time. If you change your PCP, you will receive a new ID card. Your PCP can provide primary health care services as well as coordinate your overall care. You should consult your PCP when you are sick or injured to help determine the care that is needed. If your plan requires referrals, your PCP should issue a referral to a participating specialist or facility for certain services. (See Referral Policy for details.) Referral Policy Check your plan documents to see if your plan requires PCP referrals for specialty care. Your plan documents will also list any direct access benefits that do not require referrals. If referrals are required, you must see your PCP first before visiting a specialist or other outpatient provider for nonemergency or nonurgent care. Your PCP will issue a referral for the services needed. If you do not get a referral when a referral is required, you may have to pay the bill yourself, or the service will be treated as nonpreferred if your plan includes out-of-network benefits. Some services may also require prior approval by us. See the Precertification section and your plan documents for details. The following points are important to remember regarding referrals. The referral is how your PCP arranges for you to be covered at the in-network benefit level for necessary, appropriate specialty care and follow-up treatment. You should discuss the referral with your PCP to understand what specialist services are being recommended and why. If the specialist recommends any additional treatments or tests beyond those referred by the PCP, you may need to get another referral from your PCP before receiving the services. Except in emergencies, all inpatient hospital services require a prior referral from your PCP and prior authorization by Aetna. Referrals are valid for one year as long as you remain an eligible member of the plan; the first visit must be within 90 days of referral issue date. In plans without out-of-network benefits, coverage for services from nonparticipating providers requires prior authorization by Aetna in addition to a special nonparticipating referral from the PCP. When properly authorized, these services are fully covered, less the applicable cost sharing. The referral (and a precertification, if required) provides that, except for applicable cost sharing (that is, copays, coinsurance and/ or deductibles), you will not have to pay the charges for covered expenses, as long as the individual seeking care is a member at the time the services are provided. M0001_M_PE_MM_90810 (09/2009)

25 Direct Access Under Aetna Medicare Open Access HMO and PPO plans you may directly access participating providers without a PCP referral, subject to the terms and conditions of the plan and cost sharing requirements. Participating providers will be responsible for obtaining any required preauthorization of services from Aetna. Refer to your specific plan documents for details. Aetna Medicare PPO plans have direct-access benefits. Direct-access benefits allow you to directly access participating providers and nonparticipating providers without a PCP referral, subject to additional cost sharing requirements. Even so, you may be able to reduce your out-of-pocket expenses considerably by using participating providers. Refer to your specific plan brochure for details. If your plan does not specifically cover direct-access benefits (self-referred or nonparticipating provider benefits) and you go directly to a specialist or hospital for nonemergency or nonurgent care without a referral, you must pay the bill yourself unless the service is specifically identified as a direct-access benefit in your plan documents. Direct Access Ob/Gyn Program This program allows female members to visit, without a referral, any participating obstetrician or gynecologist for a routine well-woman exam, including a breast exam, mammogram and a Pap smear, and for obstetric or gynecologic problems. Obstetricians and gynecologists may also refer a woman directly to other participating providers for covered obstetric or gynecologic services. All health plan preauthorization and coordination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG), an Integrated Delivery System (IDS) or a similar organization, your care must be coordinated through the IPA, the PMG or similar organization and the organization may have different referral policies. Precertification If required by your plan, some health care services, like hospitalization and certain outpatient surgery, require precertification. This means the service must be approved by Aetna before it will be covered under the plan. Check your plan documents for a complete list of services that require this approval. When reviewing a precertification request, we will verify your eligibility and make sure the service is a covered expense under your plan. We also check the cost-effectiveness of the service and we may communicate with your doctor if necessary. If you qualify, we may enroll you in one of our case management programs and have a nurse call to make sure you understand your upcoming procedure. When you visit a doctor, hospital or other provider that participates in the Aetna network, someone at the provider s office will contact Aetna on your behalf to get the approval. If your plan allows you to go outside the Aetna network of providers, you will have to get that approval yourself. In this case, it is your responsibility to make sure the service is precertified, so be sure to talk to your doctor about it. If you do not get proper authorization for out-of-network services, you may have to pay for the service yourself. You cannot request precertification after the service is performed. To precertify services, call the number shown on your Aetna ID card. M0001_M_PE_MM_90810 (09/2009)

26 Health Care Provider Network All hospitals may not be considered Aetna participating providers for all the services that you need. Your physician can contact Aetna to identify a participating facility for your specific needs. Certain PCPs are affiliated with IDSs, IPAs or other provider groups. If you select one of these PCPs you will generally be referred to specialists and hospitals within that system, association or group ( organization ). However, if your medical needs extend beyond the scope of the affiliated providers, you may request coverage for services provided by Aetna network providers that are not affiliated with the organization. In order to be covered, services provided by network providers that are not affiliated with the organization may require prior authorization from Aetna and/or the IDS or other provider groups. You should note that other health care providers (e.g. specialists) may be affiliated with other providers through organizations. For up-to-date information about how to locate inpatient and outpatient services, partial hospitalization and other behavioral health care services, please visit our DocFind directory at If you do not have Internet access and would like a printed provider directory, please contact Member Services at the toll-free number on your Aetna ID card and request a copy. Advance Directives There are three types of advance directives: Durable power of attorney appoints someone you trust to make medical decisions for you. Living will spells out the type and extent of care you want to receive. Do-not-resuscitate order states that you don t want to be given CPR if your heart stops or be intubated if you stop breathing. You can create an advance directive in several ways: Get an advance medical directive form from a health care professional. Certain laws require health care facilities that receive Medicare and Medicaid funds to ask all patients at the time they are admitted if they have an advance directive. You don t need an advance directive to receive care. But we are required by law to give you the chance to create one. Ask for an advance directive form at state or local offices on aging, bar associations, legal service programs, or your local health department. Work with a lawyer to write an advance directive. Create an advance directive using computer software designed for this purpose. If you have Medicare coverage and you are not satisfied with the way Aetna handles advance directives, you can file a complaint with your Medicare State Certification Agency. Visit for information on specific state agencies or call MEDICARE ( ) (TTY/TDD: ). Source: American Academy of Family Physicians. Advanced Directives and Do Not Resuscitate Orders. January Available at xml?printxml. Accessed February 20, M0001_M_PE_MM_90810 (09/2009)

27 Transplants and Other Complex Conditions Our National Medical Excellence Program and other specialty programs help you access covered services for transplants and certain other complex medical conditions at participating facilities experienced in performing these services. Depending on the terms of your plan of benefits, you may be limited to only those facilities participating in these programs when needing a transplant or other complex condition covered. Note: There are exceptions depending on state requirements. Emergency Care If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a pregnant woman, the health of the woman and her unborn child. Whether you are in or out of an Aetna service area, we simply ask that you follow the guidelines below when you believe you need emergency care. Call the local emergency hotline (ex. 911) or go to the nearest emergency facility. If a delay would not be detrimental to your health, call your doctor or PCP. Notify your doctor or PCP as soon as possible after receiving treatment. If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify your doctor, PCP or Aetna as soon as possible. What to Do Outside Your Aetna Medicare Service Area If you are traveling outside your Aetna Medicare service area; you are covered for emergency and urgently needed care. Urgent care may be obtained from a private practice physician, a walk-in clinic, an urgent care center or an emergency facility. Certain conditions, such as severe vomiting, earaches, sore throats or fever, are considered urgent care outside your Aetna Medicare service area and are covered in any of the above settings. If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or emergency problem does not qualify for coverage, it may be necessary to provide us with additional information. We will send you an Emergency Room Notification Report to complete, or a Member Services representative can take this information by telephone. Follow-up Care after Emergencies All follow-up care should be coordinated by your PCP. Follow-up care with nonparticipating providers is only covered with a referral from your PCP and prior authorization from Aetna. Whether you were treated inside or outside your Aetna Medicare service area, if your plan requires referrals, you must obtain a referral before any follow-up care can be covered. If your plan does not require referrals you should contact Aetna at the number on your ID card before care is received at non-network facilities. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care. PPO plans: All in-network and out-of-network follow-up care will be covered under the terms and conditions of your plan. M0001_M_PE_MM_90810 (09/2009)

28 After-Hours Care You may call your provider s office 24 hours a day, 7 days a week if you have medical questions or concerns. You may also consider visiting participating Urgent Care facilities. See your plan documents for cost-sharing provisions for urgent care services. Prescription Drugs If your plan covers outpatient prescription drugs, your plan may include a preferred drug list (also known as a drug formulary ). The preferred drug list includes prescription drugs that, depending on your prescription drug benefits plan, are covered on a preferred basis. Many drugs, including many of those listed on the preferred drug list, are subject to rebate arrangements between Aetna and the manufacturer of the drugs. Such rebates are not reflected in and do not reduce the amount you pay to your pharmacy for a prescription drug. In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a percentage of the cost of a drug or a deductible, it is possible for your cost to be higher for a preferred drug than it would for a nonpreferred drug. For information regarding how medications are reviewed and selected for the preferred drug list, please refer to or the Aetna Medicare Preferred Drug (Formulary) Guide. Printed Preferred Drug Guide information will be provided, upon request or if applicable, annually for current members and upon enrollment for new members. For more information, call Member Services at the toll-free number on your ID card. The medications listed on the preferred drug list are subject to change in accordance with applicable state law. Covered nonformulary prescription drugs may be subject to higher copayments or coinsurance under some benefit plans. Some prescription drug benefit plans may exclude from coverage certain nonformulary drugs that are not listed on the preferred drug list. If it is medically necessary for you to use such drugs, your physician, you or your authorized representative (or pharmacist in the case of antibiotics and analgesics) may contact Aetna to request coverage as a medical exception. Check your plan documents for details. In addition, certain drugs may require precertification or step therapy before they will be covered under some prescription drug benefit plans. Step therapy is a different form of precertification that requires a trial of one or more prerequisite therapy medications before a step therapy medication will be covered. If it is medically necessary for you to use a medication subject to these requirements prior to completing the step therapy, your physician, you or your authorized representative can request coverage of such drug as a medical exception. Nonprescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received and/or available upon enrollment) are not covered, and medical exceptions are not available for them. M0001_M_PE_MM_90810 (09/2009)