NEW JERSEY PLAN GUIDE

Transcription

1 Aetna Avenue Your Destination for Small Business Solutions NEW JERSEY PLAN GUIDE PLANS EFFECTIVE September 1, 2011 For businesses with 2-50 eligible employees NJ A (9/11)

2 NJ A (9/11) New Jersey plan GUIDE Health care is a journey Aetna Avenue is the way In this guide: 2 Small business commitment 3 Benefits for every stage of life 4 Medical overview 8 Medical plan options 20 Dental overview 22 Dental plan options 30 Life and disability overview 32 Life and disability plan options 33 Underwriting guidelines 36 Product specifications 40 Limitations and exclusions As a small business owner, providing value to your customers and growing your business are your top priorities. Yet, today health care is a business issue for every entrepreneur. Small businesses need health benefits and insurance plans that fit their workplace. Aetna Avenue provides employers with a choice of insurance benefits solutions. We know that choice, ease and reputation are as valuable to employers as they are to employees. Aetna offers a variety of plans for small business from medical plans, to dental, life and disability plans. Health/dental benefits and health/dental insurance plans, life and disability insurance/policies plans are offered, underwritten and/or administered by Aetna Health Inc.; Aetna Health Insurance Company; Aetna Dental Inc. and/or Aetna Life Insurance Company (Aetna).

3 CHOICE Ease Reputation For business owners and employees At Aetna, we provide employers a choice of health insurance benefits plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. Employees have access to a wide network of doctors and other providers, ensuring they have a choice in how they receive their health care. Allowing you to focus on your business Employers want to focus on their customers and growing their business not on their health insurance benefits program. Aetna makes sure that our plan designs are easy to set up, administer, use and provide support to ensure your success. In business, it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it NJ A (9/11) Medical plans supporting members on their health care journey Traditional plans Cost-sharing plans Consumer-directed health plans Dental, life and disability plans providing valuable protection DMO PPO PPO Max Freedom-of-Choice plan design Preventive Basic term life insurance Packaged life and disability plans Administration making it work for your business Aetna s plan designs automatically process health claims reimbursements, provide a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Secure and online, ebusiness makes managing health benefits easy and eliminates time-consuming, expensive paper-based processes. Ready on day one making it work for your employees Once employees are Aetna plan members, they ll have access to our various tools and resources to help them use the plans effectively from the start. Aetna Navigator our online resource for employers, members and providers Look up rates for providers, facilities and hospitals for common services and treatments. Simple Steps To A Healthier Life, an online health and wellness program Online tracking of medical claims Discount programs for eye, dental and other health care Personal Health Record, providing a complete picture of health Temporary ID cards available for members to print as needed Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. 1

4 New Jersey plan GUIDE Aetna Avenue s commitment to small business employers We know that small business owners health insurance benefits needs are often different than a larger employer s. Aetna Avenue focuses on employers with 2-50 employees, and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. Aetna s market map Guiding your small business health care journey Aetna s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee needs in order to narrow the field of plan design choices. Basic benefits for your employees Limiting the expense to your business Allowing employees to buy-up and share more of the cost You might be a Basic buyer These plans fit NJ COST-SHARING HMO NO-REFERRAL 2.1 NJ COST-SHARING HMO NO-REFERRAL 4.1 NJ COST-SHARING POS NO-REFERRAL 1.1 Employee responsibility These plans fit Do you value Consumerism s ability to make a difference Tools and resources to support consumerism Innovative plan design You might be a Value seeker NJ HMO HSA COMPATIBLE NO-REFERRAL 1.1 NJ HMO HSA COMPATIBLE NO-REFERRAL 3.1 NJ POS HSA COMPATIBLE NO-REFERRAL 1.1 Traditional benefits plans These plans fit Limiting the financial impact on employees You might be a Traditionalist NJ HMO NO-REFERRAL 2.1 NJ HMO NO-REFERRAL 3.1 NJ POS NO-REFERRAL 3.1 2

5 Health insurance benefits for every stage of life Young Singles Cost-sharing plans Consumer-directed health plans Young Families Traditional plans Consumer-directed health plans Established FAMILIES Cost-sharing plans Consumer-directed health plans Young singles Includes singles and couples without children Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since they re probably on a budget, they might want an affordable policy with lower monthly payments and modest out-of-pocket costs that also provides for quality preventive care, prescription drug coverage and financial protection to help safeguard their assets. Young families Includes married couples and single parents with young children and teens Children tend to get sick more than adults do which means employees and their pediatricians get to know each other quite well. It also means they re probably looking for health coverage with lower fees for office visits, lower monthly payments and caps on their out-of-pocket expenses. And, of course, they can benefit from quality preventive care for the entire family. Established families Includes married couples and single parents with teens and college-age children As the children get older, the entire family s needs change. Time management is important for active parents and children. Teenagers still need checkups and care for injuries and illness, while parents need to start thinking about their own needs, like plan designs that cover preventive care and screenings and promote a healthy lifestyle. And college brings financial concerns to the forefront, as well as the need for a national network. Empty nesters Includes men and women age 55 and over with no children at home The kids are leaving home. It s a wistful time, but also an exciting one. What are the plans? Travel? Leisure? Reassessing health coverage needs? These employees are probably looking for a policy that combines financial security with quality coverage for prescriptions, hospital inpatient/outpatient services and emergency care. Empty Nesters Cost-sharing plans Consumer-directed health plans 3

6 New Jersey plan GUIDE Aetna Avenue Medical Overview New Jersey provider network* All plans are available in all New Jersey counties. Northeast Region Small Group Sales Support Center: Wellness On Us SM Wellness for employees means a healthier business for employers. Our small business plans in New Jersey offer $0 copays for network eye exams on top of $0 copay for network preventive care. It s one more way for us to help employees get a step closer to better health. See what employees can get for $0** Immunizations $0 copay Routine vision exams $0 copay Routine physicals $0 copay Child wellness visits $0 copay Routine mammogram $0 copay Routine ob/gyn visits $0 copay Bergen Essex Hudson Hunterdon Middlesex Monmouth Morris Ocean Passaic Somerset Sussex Union Warren PRODUCT OVERVIEW Product Name Aetna HMO Aetna HMO No- Referral Product Description A Health Maintenance Organization (HMO) uses a network of participating providers. Each family member selects a primary care physician (PCP) participating in our network. The PCP provides routine and preventive care and helps coordinate the member s total health care. The PCP refers members to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered except for emergency, urgently needed care or direct access benefits, unless approved by the HMO in advance of receiving services. A Health Maintenance Organization (HMO) uses a network of participating providers. Each family member may select a primary care physician (PCP) participating in our network to provide routine and preventive care and can help coordinate the member s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care. PCP Required Referrals Required Network Yes Yes HMO Yes/ Optional No HMO (Aetna Open Access ) Mid-Atlantic Small Group Sales Support Center: AETNA (2-3862) Atlantic Burlington Camden Cape May Cumberland Gloucester Mercer Salem Aetna POS Aetna POS No- Referral Aetna Indemnity The Aetna POS plan is a two-tiered product that allows members to access care in one of two ways: PCP Referred, network, or; Self-Referred, network or non-network. Members have lower out-of-pocket costs when they use the HMO (referred) tier of the plan and follow the PCP referral process. Member cost sharing increases if members decide to self refer network or non-network. The Aetna POS No-Referral plan is a two-tiered product that allows members to access care network or non-network. Members have lower out-of-pocket costs when they use the network tier of the plan. Member cost sharing increases if members decide to go non-network. Members may go to their PCP or directly to a participating specialist without a referral. It is their choice, each time they seek care. The Aetna indemnity plan option is available for employees who live outside the plan s network service area. Members coordinate their own health care and may access any recognized provider for covered services without a referral. Yes Yes/ Optional Yes for PCP Referred Care; No for Self- Referred Care No QPOS No No N/A Aetna Choice POS (Open Access) *Network subject to change. **Standard Health Benefit Plans and Consumer-directed PPO plans apply $0 copay for network preventive care as required by federal legislation. 4

7 MEDICAL AETNA HIGH DEDUCTIBLE HSA- COMPATIBLE PLANS Aetna High Deductible HSA-compatible plans are compatible with a Health Savings Account (HSA). HSA-compatible plans provide integrated medical and pharmacy benefits. Preventive care services are waived from the deductible. HSAs provide employers and their qualified employees with an affordable tax advantaged solution that allows them to better manage their qualified medical and dental expenses. Employees can build a savings fund to assist in covering their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be taxdeductible (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. Note: Employers and employees should consult with their tax advisor to determine eligibility requirements and tax advantages for participation in the HSA plan. 5

8 New Jersey plan GUIDE Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher outof-pocket health care expenses. Aetna s consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families, while helping lower employers costs. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to save them time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium only plan (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. Flexible savings account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health Care Spending Accounts allow employees to set aside pretax dollars to pay for outof-pocket expenses, as defined by the IRS. Dependent Care Spending Accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit reimbursement account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Health information programs provide general health information and are not a substitute for diagnosis and treatment by a physician or other health care professional. Information subject to change. 6

9 MEDICAL Health Savings Account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with an HSA-compatible highdeductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. MEMBER S HSA Plan HSA Account You own your HSA Contribute tax free You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free Today Use for qualified expenses with tax free dollars Future Plan for future and retiree health-related costs High-deductible health plan Eligible network preventive care services will not be subject to the deductible You pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% 7

10 New Jersey plan GUIDE CONSUMER-DIRECTED HMO HSA COMPATIBLE PLAN OPTIONS Plan Options NJ HMO HSA COMPATIBLE NO-REFERRAL * NJ HMO HSA COMPATIBLE NO-REFERRAL * Member Benefits Network Network Network No Referral Needed No Referral Needed No Referral Needed NJ HMO HSA COMPATIBLE NO-REFERRAL * Plan Coinsurance 100% after deductible 100% after deductible 100% after deductible Benefit Year Deductible 1 (All covered prescription drug and medical expenses, except preventive services, apply to the deductible) Benefit Year Maximum Out-of-Pocket 2 (All amounts paid as deductible, copayment and coinsurance for covered services and supplies apply toward the Maximum Out-of-Pocket) $1,650 single subscriber $3,300 family $3,300 single subscriber $6,600 family $2,000 single subscriber $4,000 family $4,000 single subscriber $8,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply) Routine GYN Exams (Limited to one exam and Pap smear per 365 days) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one mammogram per benefit year for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary) Routine Eye Exam (One exam per 24 months) $2,500 single subscriber $5,000 family $5,000 single subscriber $10,000 family Glasses and Contact Lens Reimbursement $100/24 month period $100/24 month period $100/24 month period Aetna Vision SM Discount Program Included Included Included Primary Physician Office Visit $20 copay after deductible $30 copay after deductible $30 copay after deductible Specialist Office Visit $40 copay after deductible $50 copay after deductible $50 copay after deductible Outpatient Services Lab $15 copay after deductible $15 copay after deductible $15 copay after deductible Outpatient Services X-ray $40 copay after deductible $50 copay after deductible $50 copay after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (30 visits per benefit year) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year) Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per benefit year) Durable Medical Equipment ($2,500 Benefit Year Maximum) Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) 80% after deductible 70% after deductible 50% after deductible $25 copay after deductible $25 copay after deductible $25 copay after deductible $20 copay after deductible $20 copay after deductible $20 copay after deductible $20 copay after deductible $20 copay after deductible $20 copay after deductible 50% after deductible 50% after deductible 50% after deductible $300 copay per day, 5 day copay maximum per admission, after deductible $400 copay per day, 5 day copay maximum per admission, after deductible $500 copay per day, 5 day copay maximum per admission, after deductible Outpatient Surgery: Hospital Outpatient Facility $150 copay after deductible $200 copay after deductible $250 copay after deductible Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility $150 copay after deductible $200 copay after deductible $250 copay after deductible Emergency Room 80% after deductible 70% after deductible 50% after deductible Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Integrated with Medical Deductible Integrated with Medical Deductible Integrated with Medical Deductible Prescription Drugs: 30-day supply Retail or Mail Order: day supply Rx cost-shares will apply after deductible is met: Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Rx cost-shares will apply after deductible is met: Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Rx cost-shares will apply after deductible is met: Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Rx cost-shares will apply after deductible is met: Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Contraceptives and Diabetic Supplies Included Included Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage Included Included Included (TOC) for Prior Authorization + *Optional Features: Rx cost-shares will apply after deductible is met: Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Rx cost-shares will apply after deductible is met: Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Benefit Year: Plans are available on a calendar or plan year basis. Employer will elect one of two funding options: (i) funding 50% or less or (ii) funding more than 50% of the single subscriber deductible per benefit year. Employer changes, requested during the year or upon renewal of the plan, to the elected funding option will be administered as a benefits plan change. See page 18 for important plan provisions. 8

11 MEDICAL CONSUMER-DIRECTED POS HSA COMPATIBLE PLAN OPTIONS Plan Options NJ POS HSA COMPATIBLE NO-REFERRAL * NJ POS HSA COMPATIBLE NO-REFERRAL * Member Benefits Network Non-Network 3 Network Non-Network 3 No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance 100% after deductible 60% after deductible 100% after deductible 50% after deductible Benefit Year Deductible 1 (All covered prescription drug and medical expenses, except preventive services, apply to the deductible) Benefit Year Maximum Out-of-Pocket 2 (All amounts paid as deductible, copayment and coinsurance for covered services and supplies apply toward the Maximum Out-of-Pocket) $1,650 single subscriber $3,300 family $3,300 single subscriber $6,600 family $3,300 single subscriber $6,600 family $6,600 single subscriber $13,200 family $2,000 single subscriber $4,000 family $4,000 single subscriber $8,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. Network and non-network combined) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Network and non-network combined) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one mammogram per benefit year for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary. Network and non-network combined) Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per benefit year for all preventive care, except $750 combined maximum per benefit year for all preventive care for a dependent child from birth until the end of the benefit year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. $4,000 single subscriber $8,000 family $8,000 single subscriber $16,000 family Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per benefit year for all preventive care, except $750 combined maximum per benefit year for all preventive care for a dependent child from birth until the end of the benefit year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Routine Eye Exam (One exam per 24 months) Not Covered Not Covered Glasses and Contact Lens Reimbursement $100/24 month period. Network and non-network combined. $100/24 month period. Network and non-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $20 copay after deductible 60% after deductible $30 copay after deductible 50% after deductible Specialist Office Visit $40 copay after deductible 60% after deductible $50 copay after deductible 50% after deductible Outpatient Services Lab $15 copay after deductible 60% after deductible $15 copay after deductible 50% after deductible Outpatient Services X-ray $40 copay after deductible 60% after deductible $50 copay after deductible 50% after deductible Outpatient Complex Imaging 80% after deductible 60% after deductible 70% after deductible 50% after deductible (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services $25 copay after deductible 60% after deductible $25 copay after deductible 50% after deductible (30 visits per benefit year. Network and non-network combined) Outpatient Physical/Occupational Therapy $20 copay after deductible 60% after deductible $20 copay after deductible 50% after deductible (Physical and occupational therapy combined, 30 visits per benefit year. Network and non-network combined) Outpatient Cognitive/Speech Therapy $20 copay after deductible 60% after deductible $20 copay after deductible 50% after deductible (Cognitive and speech therapy combined, 30 visits per benefit year. Network and non-network combined) Durable Medical Equipment ($2,500 Benefit Year Maximum. Network 50% after deductible 50% after deductible 50% after deductible 50% after deductible and non-network combined) Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) 50% after deductible $300 copay per day, 5 day copay maximum per admission, after deductible 60% after deductible $400 copay per day, 5 day copay maximum per admission, after deductible Outpatient Surgery: Hospital Outpatient Facility $150 copay after deductible 60% after deductible; $200 copay after deductible 50% after deductible Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility $150 copay after deductible 60% after deductible. Maximum benefit of $2,000 per member per benefit year. $200 copay after deductible 50% after deductible. Maximum benefit of $2,000 per member per benefit year. Emergency Room 80% after deductible 80% after deductible 70% after deductible 70% after deductible Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Options 1-4: Integrated with Medical Deductible Options 1-4: Integrated with Medical Deductible Prescription Drugs: 30-day supply Retail or Mail Order: day supply Rx cost-shares will apply after deductible is met: Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Rx cost-shares will apply after deductible is met: Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Rx cost-shares will apply after deductible is met: Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Rx cost-shares will apply after deductible is met: Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Contraceptives and Diabetic Supplies Options 1-4: Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage (TOC) for Prior Authorization + *Optional Features: Options 1-3: Included Option 4: Not Applicable Options 1-4: Not Applicable Rx cost-shares will apply after deductible is met: Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Rx cost-shares will apply after deductible is met: Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Options 1-4: Included Options 1-3: Included Option 4: Not Applicable Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Rx cost-shares will apply after deductible is met: Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Rx cost-shares will apply after deductible is met: Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-4: Not Applicable Benefit Year: Plans are available on a calendar or plan year basis. Employer will elect one of two funding options: (i) funding 50% or less or (ii) funding more than 50% of the network single subscriber deductible per benefit year. Employer changes, requested during the year or upon renewal of the plan, to the elected funding option will be administered as a benefits plan change. See page 18 for important plan provisions. 9

12 New Jersey plan GUIDE CONSUMER-DIRECTED POS HSA COMPATIBLE PLAN OPTIONS Plan Options NJ POS HSA COMPATIBLE NO-REFERRAL * Member Benefits Network Non-Network 3 No Referral Needed No Referral Needed Plan Coinsurance 100% after deductible 50% after deductible Benefit Year Deductible 1 (All covered prescription drug and medical expenses, except preventive services, apply to the deductible) Benefit Year Maximum Out-of-Pocket 2 (All amounts paid as deductible, copayment and coinsurance for covered services and supplies apply toward the Maximum Out-of-Pocket) $2,500 single subscriber $5,000 family $5,000 single subscriber $10,000 family $5,000 single subscriber $10,000 family $10,000 single subscriber $20,000 family Lifetime Maximum Benefit Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. Network and non-network combined) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Network and non-network combined) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one mammogram per benefit year for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary. Network and non-network combined) Routine Eye Exam (One exam per 24 months) Glasses and Contact Lens Reimbursement Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per benefit year for all preventive care, except $750 combined maximum per benefit year for all preventive care for a dependent child from birth until the end of the benefit year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Not Covered $100/24 month period. Network and non-network combined. Aetna Vision SM Discount Program Included Not Covered Primary Physician Office Visit $30 copay after deductible 50% after deductible Specialist Office Visit $50 copay after deductible 50% after deductible Outpatient Services Lab $15 copay after deductible 50% after deductible Outpatient Services X-ray $50 copay after deductible 50% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (30 visits per benefit year. Network and non-network combined) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per benefit year. Network and non-network combined) Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per benefit year. Network and non-network combined) Durable Medical Equipment ($2,500 Benefit Year Maximum. Network and non-network combined) 50% after deductible 50% after deductible $25 copay after deductible 50% after deductible $20 copay after deductible 50% after deductible $20 copay after deductible 50% after deductible 50% after deductible 50% after deductible Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) $500 copay per day, 5 day copay maximum per admission, after deductible 50% after deductible Outpatient Surgery: Hospital Outpatient Facility $250 copay after deductible 50% after deductible Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility $250 copay after deductible 50% after deductible. Maximum benefit of $2,000 per member per benefit year. Emergency Room 50% after deductible 50% after deductible Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Options 1-4: Integrated with Medical Deductible Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Prescription Drugs: 30-day supply Retail or Mail Order: day supply Rx cost-shares will apply after deductible is met: Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Rx cost-shares will apply after deductible is met: Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Rx cost-shares will apply after deductible is met: Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Rx cost-shares will apply after deductible is met: Options 13: Not Covered Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Contraceptives and Diabetic Supplies Options 1-4: Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage (TOC) for Prior Authorization + Options 1-3: Included Option 4: Not Applicable Options 1-4: Not Applicable *Optional Features: Benefit Year: Plans are available on a calendar or plan year basis. Employer will elect one of two funding options: (i) funding 50% or less or (ii) funding more than 50% of the network single subscriber deductible per benefit year. Employer changes, requested during the year or upon renewal of the plan, to the elected funding option will be administered as a benefits plan change. See page 18 for important plan provisions. 10

13 COST-SHARING HMO PLAN OPTIONS Plan Options NJ COST-SHARING HMO NO-REFERRAL 1.1 +* NJ COST-SHARING HMO NO-REFERRAL 2.1 +* NJ COST-SHARING HMO NO-REFERRAL 3.1 +* Member Benefits Network Network Network Network NJ COST-SHARING HMO NO-REFERRAL 4.1 +* No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance 80% after deductible 70% after deductible 60% after deductible 50% after deductible MEDICAL Calendar Year Deductible 1 (Deductible applies only to in-network inpatient hospital-type services/outpatient surgery) $1,000 per member $2,000 family $1,500 per member $3,000 family $2,000 per member $4,000 family $2,500 per member $5,000 family Calendar Year Maximum Out-of-Pocket 2 (Prescription drugs, including self-injectables, do not apply toward the Maximum Out-of-Pocket) $1,500 per member $3,000 family $3,000 per member $6,000 family $5,000 per member $10,000 family $5,000 per member $10,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply) Routine GYN Exams (Limited to one exam and Pap smear per 365 days) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one annual mammogram for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary) Routine Eye Exam (One exam per 24 months) Glasses and Contact Lens Reimbursement $100/24 month period $100/24 month period $100/24 month period $100/24 month period Aetna Vision SM Discount Program Included Included Included Included Primary Physician Office Visit $20 copay, $20 copay, $30 copay, $30 copay, Specialist Office Visit $40 copay, $40 copay, $50 copay, $50 copay, Outpatient Services Lab Outpatient Services X-ray $40 copay, $40 copay, $50 copay, $50 copay, Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) 80%, 70%, 60%, 50%, Chiropractic Services (30 visits per calendar year) $25 copay, $25 copay, $25 copay, $25 copay, Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year) $20 copay, $20 copay, $20 copay, $20 copay, Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per calendar year) $20 copay, $20 copay, $20 copay, $20 copay, Durable Medical Equipment ($2,500 Calendar Year Maximum) 50%, 50%, 50%, 50%, Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) 80% after deductible 70% after deductible 60% after deductible 50% after deductible Outpatient Surgery: Hospital Outpatient Facility 80% after deductible 70% after deductible 60% after deductible 50% after deductible Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility 80% after deductible 70% after deductible 60% after deductible 50% after deductible Emergency Room 80%, 70%, 60%, 50%, Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Not Applicable Not Applicable Not Applicable Not Applicable Prescription Drugs: 30-day supply Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Retail or Mail Order: day supply Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Contraceptives and Diabetic Supplies Included Included Included Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage Included Included Included Included (TOC) for Prior Authorization + *Optional Features: Referral Option: NJ COST-SHARING HMO 1.1 Referral Option: NJ COST-SHARING HMO 2.1 Referral Option: NJ COST-SHARING HMO 3.1 Referral Option: NJ COST-SHARING HMO 4.1 See page 18 for important plan provisions. 11

14 New Jersey plan GUIDE COST-SHARING POS PLAN OPTIONS Plan Options NJ COST-SHARING POS NO-REFERRAL * NJ COST-SHARING POS NO-REFERRAL * Member Benefits Network Non-Network 3 Network Non-Network 3 No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance 80% after deductible 60% after deductible 70% after deductible 50% after deductible Calendar Year Deductible 1 (Deductible applies only to in-network inpatient hospital-type services/outpatient surgery) Calendar Year Maximum Out-of-Pocket 2 (Prescription drugs, including self-injectables, do not apply toward the Maximum Out-of-Pocket) $1,500 per member $3,000 family $5,000 per member $10,000 family $3,000 per member $6,000 family $10,000 individual $20,000 family $2,000 per member $4,000 family $5,000 per member $10,000 family $4,000 per member $8,000 family $10,000 individual $20,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. Network and non-network combined) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Network and non-network combined) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one annual mammogram for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary. Network and non-network combined) Routine Eye Exam (One exam per 24 months) Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Not Covered Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Not Covered Glasses and Contact Lens Reimbursement $100/24 month period. Network and non-network combined. $100/24 month period. Network and non-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $30 copay, 60% after deductible $30 copay, 50% after deductible Specialist Office Visit Outpatient Services Lab Outpatient Services X-ray Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (30 visits per calendar year. Network and non-network combined) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Network and non-network combined) Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per calendar year. Network and non-network combined) Durable Medical Equipment ($2,500 Calendar Year Maximum. Network and non-network combined) Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) $50 copay, $50 copay, 80%, $25 copay, $20 copay, $20 copay, 50%, 60% after deductible $50 copay, 60% after deductible 60% after deductible $50 copay, 60% after deductible 70%, 60% after deductible $25 copay, 60% after deductible $20 copay, 60% after deductible $20 copay, 50% after deductible 50%, 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 80% after deductible 60% after deductible 70% after deductible 50% after deductible Outpatient Surgery: Hospital Outpatient Facility 80% after deductible 60% after deductible 70% after deductible 50% after deductible Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility Emergency Room 80%, Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Prescription Drugs: 30-day supply Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Retail or Mail Order: day supply Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. 80% after deductible 60% after deductible. Maximum benefit of $2,000 per member per calendar year. 80%, Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Contraceptives and Diabetic Supplies Options 1-4: Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage (TOC) for Prior Authorization + Options 1-3: Included Option 4: Not Applicable Options 1-4: Not Applicable 70% after deductible 50% after deductible. Maximum benefit of $2,000 per member per calendar year. 70%, Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non- Network Medical Deductible and Coinsurance. Options 1-4: Included Options 1-3: Included Option 4: Not Applicable 70%, Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-4: Not Applicable *Optional Features: Referral Option: NJ COST-SHARING POS 1.1 Referral Option: NJ COST-SHARING POS 2.1 See page 18 for important plan provisions. 12

15 TRADITIONAL HMO PLAN OPTIONS MEDICAL Plan Options NJ HMO NO- REFERRAL 1.1 +* NJ HMO NO- REFERRAL 2.1 +* NJ HMO NO- REFERRAL 3.1 +* NJ HMO NO- REFERRAL 4.1 +* Member Benefits Network Network Network Network No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance 100% 100% 70% 50% Calendar Year Deductible N/A N/A N/A N/A Calendar Year Maximum Out-of-Pocket 2 (Prescription drugs, including self-injectables, do not apply toward the Maximum Out-of-Pocket) $1,500 per member $3,000 family $2,500 per member $5,000 family $5,000 per member $10,000 family $5,000 per member $10,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply) Routine GYN Exams (Limited to one exam and Pap smear per 365 days) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one annual mammogram for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary) Routine Eye Exam (One exam per 24 months) $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Glasses and Contact Lens Reimbursement $100/24 month period $100/24 month period $100/24 month period $100/24 month period Aetna Vision SM Discount Program Included Included Included Included Primary Physician Office Visit $20 copay $30 copay $30 copay $30 copay Specialist Office Visit $40 copay $50 copay $50 copay $50 copay Outpatient Services Lab $0 copay $0 copay $0 copay $0 copay Outpatient Services X-ray $40 copay $50 copay $50 copay $50 copay Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (30 visits per calendar year) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year) Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per calendar year) Durable Medical Equipment ($2,500 Calendar Year Maximum) 80% 70% 70% 50% $25 copay $25 copay $25 copay $25 copay $20 copay $20 copay $20 copay $20 copay $20 copay $20 copay $20 copay $20 copay 50% 50% 50% 50% Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) $250 copay per day, 5 day copay maximum per admission $500 copay per day, 5 day copay maximum per admission 70% 50% Outpatient Surgery: Hospital Outpatient Facility $250 copay $500 copay 70% 50% Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility $250 copay $500 copay 70% 50% Emergency Room 80% 70% 70% 50% Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Not Applicable Not Applicable Not Applicable Not Applicable Prescription Drugs: 30-day supply Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Retail or Mail Order: day supply Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Contraceptives and Diabetic Supplies Included Included Included Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage Included Included Included Included (TOC) for Prior Authorization + *Optional Features: Referral Option: NJ HMO 1.1 Referral Option: NJ HMO 2.1 Referral Option: NJ HMO 3.1 Referral Option: NJ HMO 4.1 See page 18 for important plan provisions. 13

16 New Jersey plan GUIDE TRADITIONAL POS PLAN OPTIONS Plan Options NJ POS NO-REFERRAL * NJ POS NO-REFERRAL * Member Benefits Network Non-Network 3 Network Non-Network 3 No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance 100% after deductible 60% after deductible 100% after deductible 50% after deductible Calendar Year Deductible 1 N/A $1,000 per member $2,000 family Calendar Year Maximum Out-of-Pocket 2 (Prescription drugs, including self-injectables, do not apply toward the Maximum Out-of-Pocket) $1,500 per member $3,000 family $4,500 per member $9,000 family N/A $2,500 per member $5,000 family $1,500 per member $3,000 family $7,500 per member $15,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. Network and non-network combined) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Network and non-network combined) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one annual mammogram for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary. Network and non-network combined) Routine Eye Exam (One exam per 24 months) Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Not Covered Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Not Covered Glasses and Contact Lens Reimbursement $100/24 month period. Network and non-network combined. $100/24 month period. Network and non-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $20 copay 60% after deductible $30 copay 50% after deductible Specialist Office Visit $40 copay 60% after deductible $50 copay 50% after deductible Outpatient Services Lab $0 copay 60% after deductible $0 copay 50% after deductible Outpatient Services X-ray $40 copay 60% after deductible $50 copay 50% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) 80% 60% after deductible 70% 50% after deductible Chiropractic Services (30 visits per calendar year. Network and non-network combined) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Network and non-network combined) Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per calendar year. Network and non-network combined) Durable Medical Equipment ($2,500 Calendar Year Maximum. Network and non-network combined) Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) $25 copay 60% after deductible $25 copay 50% after deductible $20 copay 60% after deductible $20 copay 50% after deductible $20 copay 60% after deductible $20 copay 50% after deductible 50% 50% after deductible 50% 50% after deductible $250 copay per day, 5 day copay maximum per admission 60% after deductible $500 copay per day, 5 day copay maximum per admission 50% after deductible Outpatient Surgery: Hospital Outpatient Facility $250 copay 60% after deductible $500 copay 50% after deductible Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility $250 copay 60% after deductible. Maximum benefit of $2,000 per member per calendar year. Emergency Room 80% 80%, Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Prescription Drugs: 30-day supply Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Retail or Mail Order: day supply Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-3: Not Covered Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Contraceptives and Diabetic Supplies Options 1-4: Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage (TOC) for Prior Authorization + Options 1-3: Included Option 4: Not Applicable Options 1-4: Not Applicable $500 copay 50% after deductible. Maximum benefit of $2,000 per member per calendar year. 70% 70%, Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-4: Included Options 1-3: Included Option 4: Not Applicable Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. *Optional Features: Referral Option: NJ POS 1.1 Referral Option: NJ POS 2.1 Options 1-4: Not Applicable See page 18 for important plan provisions. 14

17 TRADITIONAL POS PLAN OPTIONS Plan Options NJ POS NO-REFERRAL * NJ POS NO-REFERRAL * Member Benefits Network Non-Network 3 Network Non-Network 3 No Referral Needed No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance 70% 50% after deductible 50% 50% after deductible Calendar Year Deductible 1 N/A $2,000 per member $4,000 family Calendar Year Maximum Out-of-Pocket 2 (Prescription drugs, including self-injectables, do not apply toward the Maximum Out-of-Pocket) $5,000 per member $10,000 family $10,000 per member $20,000 family N/A $5,000 per member $10,000 family $2,500 per member $5,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Wellness On Us SM Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. Network and non-network combined) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Network and non-network combined) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one annual mammogram for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary. Network and non-network combined) Routine Eye Exam (One exam per 24 months) Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Not Covered $10,000 per member $20,000 family Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Not Covered Glasses and Contact Lens Reimbursement $100/24 month period. Network and non-network combined. $100/24 month period. Network and non-network combined. Aetna Vision SM Discount Program Included Not Covered Included Not Covered Primary Physician Office Visit $30 copay 50% after deductible $30 copay 50% after deductible Specialist Office Visit $50 copay 50% after deductible $50 copay 50% after deductible Outpatient Services Lab $0 copay 50% after deductible $0 copay 50% after deductible Outpatient Services X-ray $50 copay 50% after deductible $50 copay 50% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (30 visits per calendar year. Network and non-network combined) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Network and non-network combined) Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per calendar year. Network and non-network combined) Durable Medical Equipment ($2,500 Calendar Year Maximum. Network and non-network combined) Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) 70% 50% after deductible 50% 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible $20 copay 50% after deductible $20 copay 50% after deductible $20 copay 50% after deductible $20 copay 50% after deductible 50% 50% after deductible 50% 50% after deductible 70% 50% after deductible 50% 50% after deductible Outpatient Surgery: Hospital Outpatient Facility 70% 50% after deductible 50% 50% after deductible Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility 70% 50% after deductible. Maximum benefit of $2,000 per member per calendar year. Emergency Room 70% 70%, Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Prescription Drugs: 30-day supply Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Retail or Mail Order: day supply Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Contraceptives and Diabetic Supplies Options 1-4: Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage (TOC) for Prior Authorization + Options 1-3: Included Option 4: Not Applicable Options 1-4: Not Applicable 50% 50% after deductible. Maximum benefit of $2,000 per member per calendar year. 50% 50%, Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-4: Included Options 1-3: Included Option 4: Not Applicable *Optional Features: Referral Option: NJ POS 3.1 Referral Option: NJ POS 4.1 MEDICAL Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-4: Not Applicable See page 18 for important plan provisions. 15

18 New Jersey plan GUIDE TRADITIONAL HMO AND POS PLAN OPTIONS STANDARD HEALTH BENEFIT OPTIONS Plan Options NJ SEH HMO NO-REFERRAL * NJ SEH POS NO-REFERRAL * Member Benefits Network Network Non-Network 3 No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance 100% 100% 70% after deductible Calendar Year Deductible 1 N/A N/A $2,500 per member $5,000 family Calendar Year Maximum Out-of-Pocket 2 (Prescription drugs, including self-injectables, do not apply toward the Maximum Out-of-Pocket) $5,000 per member $10,000 family $5,000 per member $10,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Preventive Care Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply. Network and non-network combined) Routine GYN Exams (Limited to one exam and Pap smear per 365 days. Network and non-network combined) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one annual mammogram for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary. Network and non-network combined) $5,000 per member $10,000 family $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Routine Eye Exam Not Covered Not Covered Not Covered Glasses and Contact Lens Reimbursement Not Covered Not Covered Not Covered Aetna Vision SM Discount Program Included Included Not Covered Primary Physician Office Visit $50 copay $50 copay 70% after deductible Specialist Office Visit $50 copay $50 copay 70% after deductible Outpatient Services Lab $15 copay $15 copay 70% after deductible Outpatient Services X-ray $50 copay $50 copay 70% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Chiropractic Services (30 visits per calendar year. Network and non-network combined) Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year. Network and non-network combined) Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per calendar year. Network and non-network combined) Durable Medical Equipment (Unlimited Calendar Year Maximum. Network and non-network combined) Inpatient Hospital (Including Inpatient Mental Health and Substance Abuse) $50 copay $50 copay 70% after deductible $20 copay $20 copay 70% after deductible $20 copay $20 copay 70% after deductible $20 copay $20 copay 70% after deductible $0 copay $0 copay 70% after deductible $400 copay per day, 5 day copay maximum per admission; $4,000 calendar year copay maximum $400 copay per day, 5 day copay maximum per admission; $4,000 calendar year copay maximum 70% after deductible Outpatient Surgery: Hospital Outpatient Facility $50 copay $50 copay 70% after deductible Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility $50 copay $50 copay 70% after deductible Emergency Room $100 copay $100 copay $100 copay Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Not Applicable Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Prescription Drugs: 30-day supply Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Retail or Mail Order: day supply Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 1: $15/$35/$60 Option 2: $20/$40/$70 Option 3: $15/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Option 1: $30/$70/$120 Option 2: $40/$80/$140 Option 3: $30/50% Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Options 1-3: Not Applicable Option 4: Integrated with Medical Deductible Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Option 4: Not Covered under Rx Plan. Subject to Non-Network Medical Deductible and Coinsurance. Contraceptives and Diabetic Supplies Options 1-4: Included Options 1-4: Included Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy 90 Day Transition of Coverage Included Options 1-3: Included (TOC) for Prior Authorization + Option 4: Not Applicable *Optional Features: Referral Option: NJ SEH HMO 1.1 Options 1-4: Not Applicable Referral Option: NJ SEH POS 1.1 See page 18 for important plan provisions. 16

19 MEDICAL TRADITIONAL INDEMNITY PLAN OPTIONS STANDARD HEALTH BENEFIT OPTIONS Plan Options NJ INDEMNITY PLAN A2 NJ INDEMNITY PLAN C NJ INDEMNITY PLAN D Member Benefits Non-Network 3 Non-Network 3 Non-Network 3 No Referral Needed No Referral Needed No Referral Needed Plan Coinsurance 80% after deductible for Inpatient Hospital Care; 50% after deductible for All Other Covered Charges 70% after deductible 80% after deductible Calendar Year Deductible 1 $250 per member $750 family $1,000 per member $2,000 family $500 per member $1,000 family Calendar Year Maximum Out-of-Pocket 2 (All amounts paid as deductible, copayment and coinsurance for covered services and supplies apply toward the Maximum Out-of-Pocket) $7,750 per member $4,000 per member $8,000 family $2,500 per member $5,000 family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Preventive Care Well-Baby/Child and Adult Physical Exams (Age and frequency schedules apply) Routine GYN Exams (Includes Pap smear and related expenses) Routine Mammograms (Limited to one baseline mammogram for ages 35 through 39; one annual mammogram for ages 40 and over; and members under age 40 with a family history of breast cancer or other breast cancer risk factors as medically necessary.) Calendar Year Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited to $100 per Covered Person and $300 per Family. See Covered Charges with Special Limitations section of the plan documents. Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Preventive Care Benefit: No deductible or coinsurance applies. Benefits are limited. $500 combined maximum per calendar year for all preventive care, except $750 combined maximum per calendar year for all preventive care for a dependent child from birth until the end of the calendar year in which the dependent child attains age 1. See Covered Charges with Special Limitations section of the plan documents. Routine Eye Exam Not Covered Not Covered Not Covered Glasses and Contact Lens Reimbursement Not Covered Not Covered Not Covered Aetna Vision SM Discount Program Included Included Included Primary Physician Office Visit Not Covered 70% after deductible 80% after deductible Specialist Office Visit Not Covered 70% after deductible 80% after deductible Outpatient Services Lab Only covered if needed for a planned 70% after deductible 80% after deductible Outpatient Services X-ray hospital admission or surgery and if the tests are done on an outpatient 70% after deductible 80% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) basis within seven days of the planned admission or surgery. Aetna will not cover tests that are repeated after admission or before surgery, unless the admission or surgery is deferred solely due to a change in the member s health. X-ray and laboratory tests which are not performed in connection with a planned hospital admission or surgery are not covered. 70% after deductible 80% after deductible Chiropractic Services (30 visits per calendar year) Not Covered 70% after deductible 80% after deductible Outpatient Physical/Occupational Therapy (Physical and occupational therapy combined, 30 visits per calendar year) Outpatient Cognitive/Speech Therapy (Cognitive and speech therapy combined, 30 visits per calendar year) Covered only as part of an Inpatient Hospital confinement Covered only as part of an Inpatient Hospital confinement 70% after deductible 80% after deductible 70% after deductible 80% after deductible Durable Medical Equipment Not Covered 70% after deductible 80% after deductible Inpatient Hospital (Plan A2: Inpatient Mental Health and Substance Abuse are not covered. Plans C and D: Including Inpatient Mental Health and Substance Abuse) Outpatient Surgery: Hospital Outpatient Facility Outpatient Surgery: Ambulatory Surgical Center or Facility other than a Hospital Outpatient Facility Facility Charges: 80% after $250 hospital confinement copay per day; $1,250 maximum copay per period of confinement; $2,500 maximum copay per calendar year;. Physician and All Other Charges: 50% after deductible. Facility Charges: 80% after deductible. Physician and All Other Charges: 50% after deductible Facility Charges: 80% after deductible. Physician and All Other Charges: 50% after deductible 70% after deductible 80% after deductible 70% after deductible 80% after deductible 70% after deductible 80% after deductible Emergency Room (Copay waived if admitted) Not Covered unless admitted. 70% after $100 copay and deductible 80% after $100 copay and deductible Prescription Drugs (Includes Self-Injectables) Prescription Drug Deductible Integrated with Medical Deductible Integrated with Medical Deductible Integrated with Medical Deductible Prescription Drugs 80% after deductible. 70% after deductible 80% after deductible Contraceptives and Diabetic Supplies Prescription drugs are only covered while confined in a Hospital on Included Included an Inpatient basis only. Performance Drugs or Supplies for the Treatment of Erectile Dysfunction, Impotence or Sexual Dysfunction/Inadequacy Included Included 90 Day Transition of Coverage Not Applicable Not Applicable Not Applicable (TOC) for Prior Authorization + See page 19 for important plan provisions. 17

20 New Jersey plan GUIDE IMPORTANT PLAN PROVISIONS All Plan Options The federal health care reform legislation known as the Patient Protection and Affordable Care Act was signed into law on March 23, A number of new reforms are effective September 23, 2010, including coverage for dependents up to age 26, elimination of lifetime benefit dollar maximums, restriction of annual dollar maximums on essential health benefits, removal of cost sharing for preventive services and elimination of pre-existing condition exclusions for dependent children under 19 years of age. Your Aetna Avenue benefit program does comply with the new reform legislation. + This is a partial description of benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage amounts indicate what Aetna is required to pay. No Referral Provision for HSA Compatible, Cost-Sharing and Traditional HMO and POS No-Referral Plans: A member will pay the Primary Physician Office Visit cost-share when the member obtains covered benefits from any participating primary care physician. Members will pay the Specialist Office Visit cost-share when the member obtains covered benefits from any participating specialist. Transition of Coverage (TOC) for Prior Authorizations helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group s initial effective date, during which time prior authorization requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members, who have claims paid for a drug requiring prior authorization during the Transition of Coverage period, may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization for this drug. Some benefits are subject to limitations or visit maximums. Members or providers may be required to pre-certify or obtain prior approval for certain services. Note: For a summary list of Limitations and Exclusions, refer to page 40. Please refer to Aetna s Producer World website at for more detailed small business benefits descriptions. Or for more information, please contact your licensed agent or Aetna Sales Representative. HMO and POS HSA Compatible No-Referral Plans (Pages 8-10) 1 The Single Subscriber Deductible can only be met when a member is enrolled for self-only coverage with no dependent coverage. The Family Deductible can be met by a combination of family members or by any single individual within the family. Once the Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the benefit year. 2 The Single Subscriber Maximum Out-of-Pocket can only be met when a member is enrolled for self-only coverage with no dependent coverage. The Family Maximum Out-of-Pocket can be met by a combination of family members or by any single individual within the family. Once the Family Maximum Out-of-Pocket is met, all family members will be considered as having met their Maximum Out-of-Pocket for the remainder of the benefit year. 3 We cover the cost of care differently based on whether health care providers, such as doctors and hospitals, are network or non network. We want to help you understand how much Aetna pays and what you may have to pay for your non network care. As an example, you may choose a doctor in our network. You may choose to visit a non network doctor. If you choose a doctor who is non network, your Aetna health plan may pay some of that doctor s bill. When you choose non-network care, Aetna limits the amount it will pay. This limit is called the allowed amount. This amount is a standard amount based on data about what providers charge. A third-partyorganization compiles that data sent to it by Aetna and other insurers. Aetna will pay the higher amount of benefits for prosthetic and orthotic appliances. It does not matter if you get this appliance from a network or non-network provider. We will pay the higher of: Aetna s contracted rate with the network provider or the federal Medicare reimbursement schedule Your non network doctor or hospital sets the rate to charge you. It may be higher sometimes much higher than what your Aetna plan allows. Your doctor may bill you for the dollar amount that Aetna doesn t allow. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the allowed amount counts toward your deductible or maximum out-of-pocket. To learn more about how we pay non network benefits visit Aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This way of paying non network doctors and hospitals applies when you choose to get non network care. When you have no choice, we will pay the bill as if you got network care. You pay your plan s copayments, coinsurance and deductibles for your network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance and deductibles. Cost-Sharing HMO/HMO No-Referral, Cost-Sharing POS/POS No-Referral, Traditional HMO/HMO No-Referral and Traditional POS/POS No-Referral Plans (Pages 11-16) 1 Once the Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. No one family member may contribute more than the Individual Deductible amount to the Family Deductible. 2 Once the Family Maximum Out-of-Pocket is met, all family members will be considered as having met their Maximum Out-of-Pocket for the remainder of the calendar year. No one family member may contribute more than the Individual Maximum Out-of-Pocket amount to the Family Maximum Out-of-Pocket. 3 Cost-Sharing POS/POS No-Referral and Traditional POS/POS No-Referral Plans: We cover the cost of care differently based on whether health care providers, such as doctors and hospitals, are network or non network. We want to help you understand how much Aetna pays and what you may have to pay for your non network care. As an example, you may choose a doctor in our network. You may choose to visit a non network doctor. If you choose a doctor who is non network, your Aetna health plan may pay some of that doctor s bill. When you choose non-network care, Aetna limits the amount it will pay. This limit is called the allowed amount. This amount is a standard amount based on data about what providers charge. A thirdparty-organization compiles that data sent to it by Aetna and other insurers. Aetna will pay the higher amount of benefits for prosthetic and orthotic appliances. It does not matter if you get this appliance from a network or non-network provider. We will pay the higher of: Aetna s contracted rate with the network provider or the federal Medicare reimbursement schedule Your non network doctor or hospital sets the rate to charge you. It may be higher sometimes much higher than what your Aetna plan allows. Your doctor may bill you for the dollar amount that Aetna doesn t allow. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the allowed amount counts toward your deductible or maximum out-ofpocket. To learn more about how we pay non network benefits visit Aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This way of paying non network doctors and hospitals applies when you choose to get non network care. When you have no choice, we will pay the bill as if you got network care. You pay your plan s copayments, coinsurance and deductibles for your network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance and deductibles. 18