Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Arizona 2 100 plan guide The health of business, well planned. Plans effective December 1, 2012 For businesses with 2-100 eligible employees www.aetna.com 14.02.970.1-AZ L (2/13)
Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 employees. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. Aetna is committed to helping employers build healthy businesses. In today s rapidly changing economy, we recognize the need for less expensive, less complex health plan choices. Now, Aetna offers a variety of newly streamlined medical and dental benefits and insurance plans to provide more affordable options and to help simplify plan selection and administration. In this guide: 5 Small business commitment 5 Benefits for every stage of life 6 Medical overview 10 Medical plan options 22 Savings Plus & Aetna Whole Health plans 28 Dental overview 30 Dental plan options 40 Life & disability overview 43 Life & disability plan options 45 Underwriting guidelines 57 Product specifications 65 Limitations and exclusions 68 Group enrollment checklist 70 Contact information 71 Member services Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/ policies are offered, and/or underwritten and/or administered by Aetna Health Inc., Aetna Health Insurance Company and/ or Aetna Life Insurance Company (Aetna). 2
Women s preventive health benefits New changes effective August 1, 2012 As you may know, the Affordable Care Act (ACA, or Health Care Reform law) includes changes that are being phased in over a number of years. The latest set of changes includes additional benefits for certain Women s Preventive Health Services. When plans renew or are effective on or after August 1, 2012, all of the following women s health services will be considered preventive (some were already covered). These services generally will be covered at no cost share, when provided in network: Well-woman visits (annually and now including prenatal visits) Screening for gestational diabetes Human papillomavirus (HPV) DNA testing Counseling for sexually transmitted infections Counseling and screening for human immunodeficiency virus (HIV) Screening and counseling for interpersonal and domestic violence Breastfeeding support, supplies and counseling Generic formulary contraceptives are covered without member cost-share (for example, no copayment). Certain religious organizations or religious employers may be exempt from offering contraceptive services 3
Employers and their employees can benefit from Affordable plan options Online self-service tools and capabilities Enhanced services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs With Aetna, we know it s about... Options We provide a variety of health benefits and insurance plan options to help meet your employees needs, including medical, dental, disability and life insurance. And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care. Medical plans HMO/HNO PPO Consumer-directed health plans (CDHPs) Savings Plus Aetna Whole Health Dental plans DMO PPO PPO Max Freedom-of-Choice plan design Preventive Life and disability plans Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Packaged life and disability plans Short-term disability Long-term disability Simplicity We know that the health of your business is your top priority. Aetna s streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management. Aetna makes it easy to manage health insurance benefits with simplified enrollment, billing, and claims processing so you can focus on what matters most. Trust We work hard to provide health plan solutions you can trust. Our account executives, underwriters, and customer service representatives are committed to providing small businesses and their employees with service and care they can trust. Aetna resources are designed to fortify the health of your business Track medical claims and take advantage of online services with your Aetna Navigator secure member website. It features automated enrollment, personal health records, and printable temporary member ID cards. Get real cost and health information to help make the right care decision with an online cost of care estimator. Manage health records online with the Personal Health Record. Use the Aetna Health Connections SM disease management program, which provides personal support to members to help them manage their conditions. Leverage 24/7 access to a nurse to help with personal health-related questions. Help members work toward health goals with wellness initiatives, such as the Simple Steps To A Healthier Life online program. Take advantage of discount* programs for vision, dental, and general health care that encourage use of plan offerings. Employee Assistance Program (EAP)* Aetna s Employee Assistance Program is a confidential program that gives employees and members of their household access to useful services and support to help them manage the everyday challenges of work and home. The EAP is available at no charge to members and their family members and includes: Choice They ll find a range of resources to help them balance their personal and professional lives. Easy access EAP representatives can be reached anytime toll free at 1-866-672-5417 or on the web at www.aetnaeap.com. Management and human resource assistance Employers get unlimited phone consultations with workplace-trained clinicians who can provide help in dealing with complex employee issues that may arise. *Discounts are NOT insurance and are not underwritten by Aetna. 4
We are committed to the health of your business At Aetna, we understand that your business has unique needs. That s why we have streamlined our plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business. Health insurance benefits for every stage of life For young individuals and couples without children Lower monthly payments Modest out-of-pocket costs Quality preventive care Prescription drug coverage Financial protection...we offer: CDHPs Traditional plans Value plans Aetna Whole Health Savings Plus plans For married couples and single parents with teens and college-aged children Checkups and care for injuries and illness Preventive care and screenings that promote a healthy lifestyle National network of health care providers...we offer: CDHPs Traditional plans Aetna Whole Health Savings Plus plans For married couples and single parents with young children or teens Lower fees for office visits Lower monthly payments Caps on out-of-pocket expenses Quality preventive care for the entire family...we offer: Traditional plans Value plans Aetna Whole Health Savings Plus plans For men and women 55 years of age and over with no children at home Financial security Quality prescription drug coverage Hospital inpatient/outpatient services Emergency care...we offer: CDHPs Traditional plans Aetna Whole Health Savings Plus plans 5
Aetna Medical Overview At Aetna, we are committed to putting the member at the center of everything we do. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. 6
Medical Overview Arizona Provider Network has more than 16,000 Physicians and 95 Hospitals* Aetna HMO plan Members access care through primary care physicians With this health benefits plan, members begin by selecting a primary care physician (PCP) from Aetna s participating network of providers. Members select a PCP who will coordinate their health care needs for covered benefits or services. Each covered member of the family may choose his or her own PCP. HMO Network = 16,125 doctors and 95 hospitals Aetna HNO No Referrals No need for referrals; freedom to select a provider of choice. Aetna HNO offers all the health plan benefits of a point-ofservice plan with two easy ways to access care when members need it. Members have the freedom to visit the participating doctor or hospital of their choice for covered services. Best of all, members seeking health care do not need referrals. HNO Network = 16,125 doctors and 95 hospitals Aetna PPO The Aetna PPO insurance plan offers members the freedom to go directly to any recognized provider for covered expenses, including specialists. The PPO network is suitable for in-state rural areas. No referrals are required. PPO Network = 16,318 doctors and 95 hospitals Aetna Savings Plus plans The Aetna Savings Plus plans provide Arizona members in Maricopa, Pima and Pinal counties with the same types of coverage as other Aetna medical plans, but at a lower premium cost. Savings are generated through the use of the Savings Plus network, a quality network of local health care providers. Savings Plus Network = 11,419 doctors and 46 hospitals Aetna Whole Health plans The Aetna Whole Health plans provide Arizona members in the greater Phoenix area with the same types of coverage as other Aetna medical plans, but at a lower premium cost. Savings are generated through the use of the Aetna Whole Health network, a quality network of local health care providers. AWH Network = 5,486 doctors and 17 hospitals For additional information on Savings Plus and Aetna Whole Health plans, see page 22. What is Pick-A-Plan 3?** Pick-A-Plan 3 is Aetna Small Group s suite of plans designed specifically with small businesses in mind. These plans provide choice, flexibility and simplicity. Pick-A-Plan 3 offers the following advantages: Greater employee choice Employers can offer any 3 of the 34 available plan designs. Flexibility and affordability Employers can create a customized benefits package from any of our plan types and plan designs. Aetna offers a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Total freedom Aetna offers 34 plan choices that range in price and benefits to help meet each individual employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Easy administration Setting up this program is simple: 1. The employer chooses up to 3 plans to offer on the Employer Application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. Pick-A-Plan 3 Target Audience Plan Choices Minimum Participation Every small business with 5+ enrolled employees. Up to 3 of the 34 available plans 2 4 Enrolled Employees Single or dual option 5 or More Enrolled Employees Employer Contribution Rating Options Single, dual or triple option available 50% of the employee rate or $120 2 9 employees tabular; 10 100 employees composite *According to the Aetna Enterprise Provider Database as of May 1, 2012. Network subject to change. **Available with five or more enrolled employees. 7
Consumer-directed health plans Consumer-directed health plans are high-deductible health plans (HDHPs) designed to give individuals greater flexibility and control when purchasing care. Aetna s HDHPs are paired with account-based funds that include health savings accounts (HSAs), health reimbursement accounts (HRAs) and flexible spending accounts (FSAs). HDHP s increase the flexibility and control employers and employees have by putting them in the center of their health care. In more traditional scenarios, employees may have a higher premium associated with a low-deductible plan, and never use it. With an Aetna HDHP, the employer and employee can lower their monthly premium, and create a fund to pay for the services when needed. In an HSA or HRA fund, the monies can roll over from year to year and can be used toward future medical expenses. When a HDHP is paired with an HSA, employers and their qualified employees have a tax-advantaged solution that allows them to manage their qualified medical and dental expenses. HRAs enable employers to use tax-deductible dollars to reimburse employees for predetermined types of medical expenses. While FSAs allow individuals to use pretax salary dollars to establish an account to help pay for health care and dependent care expenses. Health Savings Account (HSA) The Aetna HealthFund HSA, when coupled with an HSA-compatible high deductible 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. Annual HSA contributions for 2013 are $3,250 per individual/ $6,450 per family. Maximums will be adjusted for the cost of living in future years. Member s HSA plan 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 in-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% Health Reimbursement Account (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 and fund rollover. 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 out-of-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. 8
COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes. These can help you manage the complex billing and notification processes that are required for COBRA compliance, while also helping to save you 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 plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. First-year POP fees with the purchase of medical and life with 5-plus enrolled employees. 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 out-of-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. Administrative Fees Fee description Health Reimbursement Arrangement (HSA) Initial setup $0 Monthly fees $0 POP Fee Initial setup* $190 Renewal $125 Health Reimbursement Arrangement (HSA) and Flexible Spending Account (FSA)** Initial setup 2 25 Employees $360 26 50 Employees $460 51 100 Employees $560 Renewal fee 2 25 Employees $235 26 50 Employees $285 51 100 Employees $335 Monthly fees*** Additional setup fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants Minimum fees $5.45 per participant $150 $10.45 per participant 2 25 Employees $25 per month minimum 26 100 Employees $50 per month minimum COBRA Annual fee 20 50 Employees $165 51 100 Employees $230 Per employee per month 20 50 Employees $0.95 51 100 Employees $1.05 Initial notice fee Transit Reimbursement Account (TRA) Annual fee $350 Transit monthly fees Parking monthly fees $3.00 per notice (includes notices at time of implementation and during ongoing administration) $4.25 per participant $3.15 per participant * Non discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. ** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. *** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month. Aetna HRAs are subject to employer-defined use and forfeiture rules. 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 subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 9
HMO & Health Network Option (HNO) Plans Plan Name AZ HMO $15/$30/$250 AZ Health Network Option (Open Access) $750 80/60 Network HMO Aetna Health Network Option (Open Access) NA PCP/Referrals Required Yes No NA Member Benefits Participating providers Participating providers Nonparticipating providers 1 Calendar-Year Plan Deductible None $750 per member $750 per member Out-of-Pocket Limit $2,000 Individual $3,000 per member $6,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Ambulance, chiropractic, DME, emergency/ urgent care and prescription drugs (including Specialty CareRx SM ) Primary Care Physician Office Visit $15 copay $20 copay; deductible Specialist Office Visit $30 copay $40 copay; deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) 40% after deductible 40% after deductible No charge No charge 40% after deductible Diagnostic Testing (X-ray, blood work) $30 copay $40 copay; deductible 40% after deductible Imaging (CT/PET scans MRI s) $100 copay 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/ Generic & brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None NA $15/$30/$50 $20/$40/$60 Not covered Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary N/A Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 20% Not covered Outpatient Surgery OP Hospital Department $250 copay 30% after deductible Outpatient Surgery Freestanding Facility $150 copay 20% after deductible 40% after deductible Inpatient Hospital Facility $250 copay per day up to 3-days per admit 20% after deductible 40% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) $30 copay 20% after deductible 40% after deductible Emergency Room $100 copay $250 copay; deductible Emergency Medical Transport $100 copay 20% after deductible Urgent Care $50 copay Primary & Specialist Physician E-Visit $10 copay $10 copay; deductible Walk-In Clinics $15 copay $20 copay; deductible Chiropractic $30 copay (Limited to 20-visits per member per calendar year) $40 copay; deductible (Limited to 20-visits per member per calendar year) Not covered Not covered 40% after deductible (No visit limits) See pages 26 27 for footnotes. 10
HMO & Health Network Option (HNO) Plans Plan Name AZ Health Network Option (Open Access) $1,000 80/60 AZ Health Network Option (Open Access) $1,500 70/50 Network Aetna Health Network Option (Open Access) NA Aetna Health Network Option (Open Access) PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $1,000 per member $1,000 per member $1,500 per member $1,500 per member Out-of-Pocket Limit $4,000 per member $8,000 per member $5,000 per member $10,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible NA Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) No charge 40% after deductible No charge 40% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 30% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/ Generic & brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None NA None NA $20/$40/$60 Not covered $20/$40/$60 Not covered Pharmacy Plan Type Four Tier Open Formulary N/A Four Tier Open Formulary N/A Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% Not covered 20% Not covered Outpatient Surgery OP Hospital Department 30% after deductible 40% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 30% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 30% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 20% after deductible 40% after deductible 30% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 20% after deductible 30% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic $10 copay; deductible $25 copay; deductible (Limited to 20-visits per member per calendar year) Not covered Not covered 40% after deductible (No visit limits) $10 copay; deductible $25 copay; deductible (Limited to 20-visits per member per calendar year) Not covered Not covered (No visit limits) See pages 26 27 for footnotes. 11
Open Choice PPO Plan Options Plan Name AZ PPO $500 80/60 $15/$30 AZ PPO $750 80/60 $20/$40 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $500 per member $500 per member $750 per member $750 per member Out-of-Pocket Limit $2,500 per member $5,000 per member $3,000 per member $6,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $15 copay; deductible $30 copay; deductible 40% after deductible $20 copay; deductible 40% after deductible $40 copay; deductible Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) 40% after deductible 40% after deductible No charge 40% after deductible No charge 40% after deductible $30 copay; deductible 40% after deductible $40 copay; deductible 40% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None None $15/$30/$50 20% after $15/$30/$50 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 40% 20% 40% Outpatient Surgery OP Hospital Department 30% after deductible 30% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 20% after deductible 40% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 20% after deductible 40% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 20% after deductible 40% after deductible 20% after deductible 40% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $15 copay; deductible $30 copay; deductible 40% after deductible $10 copay; deductible 40% after deductible $20 copay; deductible 40% after deductible $40 copay; deductible 40% after deductible 40% after deductible 40% after deductible See pages 26 27 for footnotes. 12
Open Choice PPO Plan Options Plan Name AZ PPO $1,000 80/60 $20/$40 AZ PPO $1,000 70/50 $25/$50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $1,000 per member $1,000 per member $1,000 per member $1,000 per member Out-of-Pocket Limit $4,000 per member $8,000 per member $4,000 per member $8,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $20 copay; deductible $40 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) No charge 40% after deductible No charge $40 copay; deductible 40% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 30% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 40% 20% 50% Outpatient Surgery OP Hospital Department 30% after deductible 40% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 30% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 30% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 20% after deductible 40% after deductible 30% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 20% after deductible 30% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $20 copay; deductible $40 copay; deductible 40% after deductible $10 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible See pages 26 27 for footnotes. 13
Open Choice PPO Plan Options Plan Name AZ PPO $2,000 70/50 $25/$50 AZ PPO $2,500 80/60 $25/$50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $2,000 per member $2,000 per member $2,500 per member $2,500 per member Out-of-Pocket Limit $4,500 per member $9,000 per member $5,000 per member $10,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay; deductible $25 copay; deductible Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) 40% after deductible 40% after deductible No charge No charge 40% after deductible 40% after deductible Imaging (CT/PET scans MRI s) 30% after deductible 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 50% 20% 40% Outpatient Surgery OP Hospital Department 40% after deductible 30% after deductible Outpatient Surgery Freestanding Facility 30% after deductible 20% after deductible 40% after deductible Inpatient Hospital Facility 30% after deductible 20% after deductible 40% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 30% after deductible $25 copay after deductible 40% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 30% after deductible 20% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $25 copay; deductible $10 copay; deductible $25 copay; deductible 40% after deductible 40% after deductible 40% after deductible See pages 26 27 for footnotes. 14
Open Choice PPO & Indemnity Plan Options Plan Name AZ PPO $5,000 80/60 $30/$60 AZ Indemnity $500 80% Network Open Choice PPO NA NA PCP/Referrals Required No NA NA Member Benefits Participating providers Nonparticipating providers 1 Nonparticipating providers 2 Calendar-Year Plan Deductible $5,000 per member $5,000 per member $500 per member Out-of-Pocket Limit $5,000 per member $10,000 per member $3,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Per member Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $30 copay; deductible $60 copay; deductible 40% after deductible 20% after deductible 40% after deductible 20% after deductible No charge 40% after deductible 0%; deductible $60 copay; deductible 40% after deductible 20% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None Amounts over allowable charges, ambulance, deductible, DME, emergency/urgent care, failure to precertify penalty, payments for mental disorders (2-50), substance abuse (2-50), Rx (including Specialty CareRx SM ) $20/$40/$60 20% after $20/$40/$60 Participating: $20/$40/$60 Nonparticipating: 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 40% 20% Outpatient Surgery OP Hospital Department 30% after deductible 20% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 20% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 20% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) $30 copay after deductible 40% after deductible 20% after deductible Emergency Room $250 copay; deductible 20% after deductible Emergency Medical Transport 20% after deductible 20% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $30 copay; deductible $60 copay; deductible 20% after deductible 40% after deductible Not covered 40% after deductible Not covered 40% after deductible 20% after deductible See pages 26 27 for footnotes. 15
Open Choice PPO 100% Plans Plan Name AZ PPO $2,500 100/50 $20/$40 AZ PPO $3,500 100/50 $25/$50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $2,500 Individual $5,000 Family $0 Individual $0 Family $5,000 Individual $10,000 Family $5,000 Individual $10,000 Family $3,500 Individual $7,000 Family $0 Individual $0 Family $7,000 Individual $14,000 Family $7,000 Individual $14,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) $20 copay; deductible $40 copay; deductible $25 copay; deductible Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) No charge No charge $40 copay; deductible Imaging (CT/PET scans MRI s) 0% after deductible 0% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 50% 20% 50% Outpatient Surgery OP Hospital Department 0% after deductible 0% after deductible Outpatient Surgery Freestanding Facility 0% after deductible 0% after deductible Inpatient Hospital Facility 0% after deductible 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 0% after deductible 0% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 0% after deductible 0% after deductible Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) $10 copay; deductible $20 copay; deductible $40 copay; deductible $10 copay; deductible $25 copay; deductible See pages 26 27 for footnotes. 16
Open Choice PPO 100% Plans Plan Name AZ PPO $5,000 100/50 $25/$50 Network Open Choice PPO NA PCP/Referrals Required No NA Member Benefits Participating providers Nonparticipating providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $5,000 Individual $10,000 Family $0 Individual $0 Family $10,000 Individual $20,000 Family $10,000 Individual $20,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay; deductible No charge Imaging (CT/PET scans MRI s) 0% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 50% Outpatient Surgery OP Hospital Department 0% after deductible Outpatient Surgery Freestanding Facility 0% after deductible Inpatient Hospital Facility 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) Emergency Room Emergency Medical Transport Urgent Care Primary & Specialist Physician E-Visit Walk-In Clinics Chiropractic (No visit limits) 0% after deductible $250 copay; deductible $10 copay; deductible $25 copay; deductible 0% after deductible See pages 26 27 for footnotes. 17
Open Choice PPO Value & Value Saver Plans Plan Name AZ PPO Value $2,500 80/50 AZ PPO Value Saver $7,500 100/50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible $2,500 per member $2,500 per member $7,500 Individual $10,000 Family Out-of-Pocket Limit $5,000 per member $10,000 per member $0 Individual $0 Family See pages 26 27 for footnotes. 18 $7,500 Individual $10,000 Family Unlimited Individual Unlimited Family Deductible & Out-of-Pocket Limit Accumulation Per member Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Imaging (CT/PET scans MRI s) Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay 5 ; deductible (office visit limit applies; see footnote for details) $25 copay 5 ; deductible (office visit limit applies; see footnote for details) 5 (office visit limit applies; see footnote for details) 5 (office visit limit applies; see footnote for details) Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) $20 copay; deductible 0%; after deductible No charge No charge $500 copay after deductible $40 copay; deductible for the first $1,000 per member, thereafter covered at 0% after deductible 0% after deductible $500 per member None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 50% 50% 30% 50% Outpatient Surgery OP Hospital Department 30% after deductible 0% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 0% after deductible Inpatient Hospital Facility 20% after deductible 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) See office visit benefit See office visit benefit 0% after deductible Emergency Room $250 copay after deductible 0% after deductible Emergency Medical Transport 20% after deductible 0% after deductible Urgent Care Primary & Specialist Physician E-Visit $100 copay; deductible $10 copay; deductible 0% after deductible 0% after deductible $10 copay; deductible Walk-In Clinics See office visit benefit $20 copay; deductible Chiropractic (No visit limits) $25 copay; deductible 0% after deductible
Open Choice PPO Value Saver Plans Plan Name AZ PPO Value Saver $10,000 100/50 Network Open Choice PPO NA PCP/Referrals Required No NA Member Benefits Participating providers Nonparticipating providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $10,000 Individual $10,000 Family $0 Individual $0 Family $10,000 Individual $10,000 Family Unlimited Individual Unlimited Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) $15 copay; deductible Specialist Office Visit 0%; after deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) No charge $30 copay; deductible for the first $1,000 per member, thereafter covered at 0% after deductible Imaging (CT/PET scans MRI s) 0% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply None None $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 30% 50% Outpatient Surgery OP Hospital Department 0% after deductible Outpatient Surgery Freestanding Facility 0% after deductible Inpatient Hospital Facility 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) Emergency Room Emergency Medical Transport 0% after deductible 0% after deductible 0% after deductible Urgent Care 0% after deductible 0% after deductible Primary & Specialist Physician E-Visit Walk-In Clinics $10 copay; deductible $15 copay; deductible Chiropractic (No visit limits) 0% after deductible See pages 26 27 for footnotes. 19
Open Choice PPO HSA-Compatible HDHP Plans Plan Name AZ PPO HSA HDHP $2,500 100/50 AZ PPO HSA HDHP $5,000 100/50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $2,500 Individual $5,000 Family $3,450 Individual $6,900 Family $2,500 Individual $5,000 Family $3,450 Individual $6,900 Family $5,000 Individual $10,000 Family $950 Individual $1,900 Family $5,000 Individual $10,000 Family $950 Individual $1,900 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Amounts over allowable charges, deductible and failure to precertify penalty. Amounts over allowable charges, deductible and failure to precertify penalty. Primary Care Physician Office Visit 0% after deductible 0% after deductible Specialist Office Visit 0% after deductible 0% after deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) No charge No charge Diagnostic Testing (X-ray, blood work) 0% after deductible 0% after deductible Imaging (CT/PET scans MRI s) 0% after deductible 0% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply Pharmacy Plan Type Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does accumulate toward out-of-pocket payment limit.) Integrated medical/rx deductible Integrated medical/rx deductible Integrated medical/rx deductible Integrated medical/rx deductible $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary 20% 50% 20% 50% Four Tier Open Formulary Outpatient Surgery OP Hospital Department 0% after deductible 0% after deductible Outpatient Surgery Freestanding Facility 0% after deductible 0% after deductible Inpatient Hospital Facility 0% after deductible 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 0% after deductible 0% after deductible Emergency Room $250 copay after deductible $250 copay after deductible Emergency Medical Transport 0% after deductible 0% after deductible Urgent Care 0% after deductible 0% after deductible 0% after deductible 0% after deductible Primary & Specialist Physician E-Visit 0% after deductible 0% after deductible Walk-In Clinics 0% after deductible 0% after deductible Chiropractic (No visit limits) 0% after deductible 0% after deductible See pages 26 27 for footnotes. 20
Open Choice PPO HSA-Compatible HDHP Plans Plan Name AZ PPO HSA HDHP $2,500 90/50 AZ PPO HSA HDHP $4,000 80/50 Network Open Choice PPO NA Open Choice PPO NA PCP/Referrals Required No NA No NA Member Benefits Participating providers Nonparticipating Participating providers Nonparticipating providers 1 providers 1 Calendar-Year Plan Deductible Out-of-Pocket Limit $2,500 Individual $5,000 Family $3,000 Individual $6,000 Family $2,500 Individual $5,000 Family $3,000 Individual $6,000 Family $4,000 Individual $8,000 Family $1,500 Individual $3,000 Family $4,000 Individual $8,000 Family $1,500 Individual $3,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 4 Embedded aggregate 4 Not Included In Out-of-Pocket Limit 3 Amounts over allowable charges, deductible and failure to precertify penalty. Amounts over allowable charges, deductible and failure to precertify penalty. Primary Care Physician Office Visit 10% after deductible 20% after deductible Specialist Office Visit 10% after deductible 20% after deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) No charge No charge Diagnostic Testing (X-ray, blood work) 10% after deductible 20% after deductible Imaging (CT/PET scans MRI s) 10% after deductible 20% after deductible Prescription Drug Deductible (Applies to brand and nonformulary brand drugs) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Retail: 30-day supply Mail order: two-times retail copay, up to 90-day supply Pharmacy Plan Type Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does accumulate toward out-of-pocket payment limit.) Integrated medical/rx deductible Integrated medical/rx deductible Integrated medical/rx deductible Integrated medical/rx deductible $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary 20% 50% 20% 50% Four Tier Open Formulary Outpatient Surgery OP Hospital Department 10% after deductible 20% after deductible Outpatient Surgery Freestanding Facility 10% after deductible 20% after deductible Inpatient Hospital Facility 10% after deductible 20% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 10% after deductible 20% after deductible Emergency Room $250 copay after deductible $250 copay after deductible Emergency Medical Transport 10% after deductible 20% after deductible Urgent Care 10% after deductible 10% after deductible 20% after deductible 20% after deductible Primary & Specialist Physician E-Visit 10% after deductible 20% after deductible Walk-In Clinics 10% after deductible 20% after deductible Chiropractic (No visit limits) 10% after deductible 20% after deductible See pages 26 27 for footnotes. 21
Savings Plus & Aetna Whole Health Plans Savings Plus plans Health plans designed with small businesses in mind for Maricopa, Pima and Pinal Counties.* The Aetna Savings Plus plans are helping Arizona small businesses access health services that fit their needs and their budgets. They give members access to an affordable network of health providers right in their own community. Aetna Whole Health brings you the Banner Health Network We re pleased to offer the Banner Health Network for businesses located in the greater Phoenix metropolitan area.* It s a quality provider network that helps us improve care while decreasing costs for members and employers. Your employees will find care in their own communities, with local health care providers who have skill, experience and compassion. Banner Health Network provides convenient access to an integrated network of providers dedicated to maintaining and enhancing health at the highest possible level while delivering a highly coordinated patient experience. Banner Health Network hospital locations How do the Savings Plus and Aetna Whole Health plans work? There are six different Aetna Savings Plus and Aetna Whole Health plans in Arizona, giving small businesses the flexibility and choice to best meet their needs. Each plan has two levels of benefits: Level 1: When members use the Savings Plus or the Banner Health Network to coordinate all of their care, they realize maximum savings. Level 2: Use of any other providers will result in a lower level of benefits. While members have the freedom to receive care from any hospital or physician, they realize the highest benefit level and the lowest out-of-pocket costs when they access care through the Savings Plus network. Premiums and out-of-pocket expense levels vary select the plan that s right for you and your employees. Maricopa County City Hospital Address Zip Mesa Banner Heart Hospital 6750 E. Baywood Ave. 85206 Mesa Mesa Phoenix Phoenix Glendale Gilbert Sun City Sun City West San Tan Valley Scottsdale Banner Baywood Medical Center Banner Desert Medical Center Cardon Children s Medical Center Banner Estrella Medical Center Banner Good Samaritan Medical Center Banner Thunderbird Medical Center Banner Gateway Medical Center Banner Boswell Medical Center Banner Del E. Webb Medical Center Banner Ironwood Medical Center Banner Behavioral Health Hospital 6644 E. Baywood Ave. 85206 1400 S. Dobson Rd. 85202 9201 W. Thomas Rd. 85037 1111 E. McDowell Rd. 85006 5555 W. Thunderbird Rd. 85306 1900 N. Higley Rd. 85234 10401 W. Thunderbird Blvd. 85351 14502 W. Meeker Blvd. 85375 37000 N. Gantzel Rd. 85140 7575 E. Earll Dr. 85251 Sun City West Sun City Glendale Phoenix Phoenix Mesa Gilbert Scottsdale San Tan Valley Please check the DocFind directory for a full list of providers participating in the Savings Plus and Banner Health Network. *Employers and employees must reside in an eligible area. Live/work rules do not apply. 22
Savings Plus* & Aetna Whole Health* (Banner Health Network) Plan Options Plan Name $750 80/60 $20/$40 $1,000 70/50 $25/$50 Network Savings Plus or Banner Health Network NA Savings Plus or Banner Health Network PCP/Referrals Required No NA No NA Member Benefits 1 Level 1: Network designated providers Level 2: All other providers Level 1: Network designated providers NA Level 2: All other providers Calendar-Year Plan Deductible $750 per member $1,500 per member $1,000 per member $2,000 per member Out-of-Pocket Limit $4,000 per member $8,000 per member $4,000 per member $8,000 per member Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Two-member maximum Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $20 copay; deductible $40 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) No charge 40% after deductible No charge $40 copay; deductible 40% after deductible Imaging (CT/PET scans MRI s) 20% after deductible 40% after deductible 30% after deductible Prescription Drug Deductible (Applies to all prescription drugs; preferred and nonpreferred combined) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary None None None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 50% 20% 50% Outpatient Surgery OP Hospital Department 20% after deductible 40% after deductible 30% after deductible Outpatient Surgery Freestanding Facility 20% after deductible 40% after deductible 30% after deductible Inpatient Hospital Facility 20% after deductible 40% after deductible 30% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 20% after deductible 40% after deductible 30% after deductible Emergency Room $250 copay; deductible $250 copay; deductible Emergency Medical Transport 20% after deductible 30% after deductible Urgent Care Primary Physician & Specialist E-Visit Walk-In Clinics Chiropractic $10 copay; deductible $20 copay; deductible $40 copay; deductible 40% after deductible $10 copay; deductible 40% after deductible $25 copay; deductible 40% after deductible See pages 26 27 for footnotes. 23
Savings Plus* & Aetna Whole Health* (Banner Health Network) Plan Options Plan Name $2,000 70/50 $25/$50 Value Saver $10,000 100/50 Network Savings Plus or Banner Health Network NA Savings Plus or Banner Health Network PCP/Referrals Required No NA No NA Member Benefits 1 Level 1: Network designated providers Level 2: All other providers Level 1: Network designated providers Calendar-Year Plan Deductible $2,000 per member $4,000 per member $10,000 Individual $10,000 Family Out-of-Pocket Limit $4,500 per member $9,000 per member $0 Individual $0 Family NA Level 2: All other providers $10,000 Individual $10,000 Family Unlimited Individual Unlimited Family Deductible & Out-of-Pocket Limit Accumulation Two-member maximum Embedded aggregate 3 Not Included In Out-of-Pocket Limit 3 Primary Care Physician Office Visit Specialist Office Visit Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) Diagnostic Testing (X-ray, blood work) Amounts over allowable charges, copays, deductible, DME, failure to precertify penalty and Rx (including Specialty CareRx SM ) $25 copay; deductible $15 copay; deductible Amounts over allowable charges, copays, deductible, failure to precertify penalty and Rx (including Specialty CareRx SM ) 0%; after deductible No charge No charge $30 copay; deductible for the first $1,000 per member, thereafter covered at 0% after deductible Imaging (CT/PET scans MRI s) 30% after deductible 0% after deductible Prescription Drug Deductible (Applies to all prescription drugs; preferred and nonpreferred combined) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary None None None None $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does not accumulate toward out-of-pocket payment limit.) 20% 50% 30% 50% Outpatient Surgery OP Hospital Department 30% after deductible 0% after deductible Outpatient Surgery Freestanding Facility 30% after deductible 0% after deductible Inpatient Hospital Facility 30% after deductible 0% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 30% after deductible 0% after deductible Emergency Room $250 copay; deductible 0% after deductible Emergency Medical Transport 30% after deductible 0% after deductible Urgent Care Primary Physician & Specialist E-Visit Walk-In Clinics Chiropractic $10 copay; deductible $25 copay; deductible $10 copay; deductible $15 copay; deductible 0% after deductible 0% after deductible 0% after deductible See pages 26 27 for footnotes. 24
Savings Plus* & Aetna Whole Health* (Banner Health Network) Plan Options Plan Name HSA HDHP $2,500 100/50 HSA HDHP $4,000 80/50 Network Savings Plus or Banner Health Network NA Savings Plus or Banner Health Network PCP/Referrals Required No NA No NA Member Benefits 1 Calendar-Year Plan Deductible Out-of-Pocket Limit Level 1: Network designated providers $2,500 Individual $5,000 Family $3,450 Individual $6,900 Family Level 2: All other providers $3,500 Individual $7,000 Family $4,450 Individual $8,900 Family Level 1: Network designated providers $4,000 Individual $8,000 Family $1,500 Individual $3,000 Family NA Level 2: All other providers $5,000 Individual $10,000 Family $2,500 Individual $5,000 Family Deductible & Out-of-Pocket Limit Accumulation Embedded aggregate 3 Embedded aggregate 3 Not Included In Out-of-Pocket Limit 3 Amounts over allowable charges, deductible and failure to precertify penalty. Amounts over allowable charges, deductible and failure to precertify penalty. Primary Care Physician Office Visit 0% after deductible 20% after deductible Specialist Office Visit 0% after deductible 20% after deductible Preventive Care/Screenings/Immunizations (Age and frequency schedules may apply.) No charge No charge Diagnostic Testing (X-ray, blood work) 0% after deductible 20% after deductible Imaging (CT/PET scans MRI s) 0% after deductible 20% after deductible Prescription Drug Deductible (Applies to all prescription drugs; preferred and nonpreferred combined) Prescription Drugs* Generic formulary/brand formulary/brand nonformulary Integrated medical/ Rx deductible Integrated medical/ Rx deductible Integrated medical/ Rx deductible Integrated medical/ Rx deductible $20/$40/$60 20% after $20/$40/$60 $20/$40/$60 20% after $20/$40/$60 Pharmacy Plan Type Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Four Tier Open Formulary Aetna Specialty CareRx SM Includes self-injectable, infused and oral specialty drugs (Retail and mail order up to a 30-day supply, excludes insulin, does accumulate toward out-of-pocket payment limit.) 20% 50% 20% 50% Outpatient Surgery OP Hospital Department 0% after deductible 20% after deductible Outpatient Surgery Freestanding Facility 0% after deductible 20% after deductible Inpatient Hospital Facility 0% after deductible 20% after deductible Rehabilitation Services (PT/OT) (20 visits per calendar year. Participating and nonparticipating combined.) 0% after deductible 20% after deductible Emergency Room 0% after deductible 20% after deductible Emergency Medical Transport 0% after deductible 20% after deductible Urgent Care 0% after deductible 0% after deductible 20% after deductible 20% after deductible Primary Physician & Specialist E-Visit 0% after deductible 20% after deductible Walk-In Clinics 0% after deductible 20% after deductible Chiropractic 0% after deductible 20% after deductible See pages 26 27 for footnotes. 25
Footnotes All services are subject to the deductible (if applicable) unless otherwise noted. Some benefits are subject to age and frequency schedules, limitations or visit maximums. Generic formulary contraceptives are covered without member cost share. Certain religious organizations or religious employers may be exempt from offering contraceptive services. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care and complex imaging services. 1 We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out-of-network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit www.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 www.aetna.com 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 applies when you choose to get care out-of-network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in-network. You pay cost sharing and deductibles for your in-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 cost sharing and deductibles. 2 We cover the cost of services based on whether doctors are in-network or out-of-network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who it out-of-network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. For doctors and other professionals the amount based on prevailing charges. We get this data from an external database. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit www.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 www.aetna.com 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 applies when you choose to get care out-of-network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in-network. You pay cost sharing and deductibles for your in-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 cost sharing and deductibles. 3 For groups with 2-50 eligible employees mental health and substance abuse charges do not accumulate toward the out-of-pocket limit on non-hsa HDHP plans. 4 Each covered family member only needs to satisfy his or her individual deductible/out-of-pocket limit, not the entire family deductible/out-of-pocket limit. 26
5 This plan provides limited benefits only and does not constitute a comprehensive insurance plan. As such, it may not cover all the expenses associated with your health care needs. Office visits are limited to three per member per calendar year (participating and nonparticipating) for all types of office visits combined (including physician, specialist physician, walk-in-clinics, PT/OT/ST, etc.) Routine X-rays and lab provided by the provider and billed by the provider with the office visit is included in the office visit copay. Preventive care and e-visits are not included in the three office visit benefit. * Savings Plus is available in Maricopa, Pima and Pinal counties. Managed Choice POS Open Access network using the Savings Plus Network. To locate providers go to Aetna DocFind at www.aetna.com/docfind/custom/azsavingsplus. Aetna Whole Health is available in Maricopa, and parts of Pinal counties. Managed Choice POS Open Access network using the Banner Health Network. To locate providers go to Aetna DocFind at www.aetna.com/docfind/custom/bannerhealthnetwork. Each Savings Plus and Aetna Whole Health Plan has two levels of benefits: Level 1: When members use Savings Plus or the Banner Health Network to coordinate all of their care, they realize maximum savings. Level 2: Use of any other provider will result in a lower level of benefits. While Savings Plus and Aetna Whole Health members have the freedom to receive care from any hospital or provider, they realize the highest benefit level and the lowest out-of-pocket costs when they access care through the Savings Plus or Banner Health Network. Pre-existing Conditions Exclusion Provision This plan imposes a pre-existing conditions exclusion, which may be in some circumstances (that is, creditable coverage) and may not be applicable to you. A pre-existing conditions exclusion means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within six months. Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the six month period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 12 months from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. If you had prior creditable coverage within 90-days immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be. If you had less than six months of creditable coverage immediately before the date you enrolled, your plan s pre-existing conditions exclusion period will be reduced by the amount (that is, number of days) of that prior coverage. In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any Certificates of Creditable Coverage you have. Please contact your Aetna Member Services representative at 1-888-802-3862 for PPO and 1-888-702-3862 for HMO/CPOS if you need assistance in obtaining a Certificate of Creditable Coverage from your prior carrier or if you have any questions on the information noted above. Pre-existing condition exclusion provisions are for any individual under the age of 19 and do not apply to pregnancy. Note: For late enrollees, coverage will be delayed until the plan s next open enrollment; the pre-existing exclusion will be applied from the individual s effective date of coverage. 27
Aetna Dental Plans Small business decision makers can choose from a variety of plan design options that help you offer a dental benefits and dental insurance plan that s just right for your employees. 28
Dental Overview The Mouth Matters SM Research suggests that serious gum disease, known as periodontitis, may be associated with many health problems. This is especially true if serious gum disease continues without treatment. 1 Now, here s the good news. Researchers are discovering that a healthy mouth may be important to overall health. 1 The Aetna Dental/Medical Integration SM (DMI) program,* available at no additional charge to plan sponsors that have both medical and dental coverages with Aetna, focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We proactively educate those at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care to visit the dentist. Once at the dentist s office, these at-risk members will receive enhanced dental benefits, including an extra cleaning and full coverage for certain periodontal services. The Dental Maintenance Organization (DMO) Members select a primary care dentist to coordinate their care from the available managed dental network. Each family member may choose a different primary care dentist and may switch dentists at any time through their secure Aetna Navigator member website or with a call to Member Services. If specialty care is needed, a member s primary care dentist can refer the member to a participating specialist. However, members may visit orthodontists without a referral. There are virtually no claim forms to file, and benefits are not subject to deductibles or annual maximums. PPO Max plan While the PPO Max dental insurance plan uses the PPO network, when members use out-of-network dentists the service will be covered based on the PPO fee schedule, rather than the reasonable and customary charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage. Freedom-of-Choice plan design option Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice Plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO Max Plans on a monthly basis. One blended rate is paid. Members may switch between the plans on a monthly basis by calling Member Services. Plan changes must be made by the 15 th of the month to be effective the following month. Dual option plan design In the dual option plan design,** the DMO may be packaged with any one of the PPO plans. Employees may choose between the DMO and PPO offerings at annual enrollment. Voluntary dental option The voluntary dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members services at negotiated rates and will not balance bill members for covered services. *DMI may not be available in all states. **Dual option does not apply to all preventive dental plans and to the voluntary dental plans in the 3 9 group size. 1 MayoClinic.com. Oral health: A window to your overall health. www.mayoclinic.com/health/dental/de00001 [article online]. February 5, 2011. Accessed November 2012. 29
Aetna Dental Plans 2 9 Option 1 DMO Option 2 Freedom-of-Choice Monthly selection between the DMO and PPO Max Option 3 PPO Max 1500 DMO Plan 100/80/50 DMO Plan 41 PPO Max Plan 100/70/40 Office Visit Copay $5 $10 N/A N/A Annual Deductible per Member does not apply to diagnostic & preventive services PPO Max Plan 100/80/50 None None $50; 3X family maximum $50; 3X family maximum Annual Maximum Benefit Unlimited Unlimited $1,000 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% No charge 100% 100% Comprehensive oral exam 100% No charge 100% 100% Problem-focused oral exam 100% No charge 100% 100% X-rays Bitewing single film 100% No charge 100% 100% Complete series 100% No charge 100% 100% Preventive Services Adult cleaning 100% No charge 100% 100% Child cleaning 100% No charge 100% 100% Sealants per tooth 100% $10 100% 100% Fluoride application with cleaning 100% No charge 100% 100% Space maintainers 100% $100 100% 100% Basic Services Amalgam filling 2 surfaces 80% $32 70% 80% Resin filling 2 surfaces, anterior 80% $55 70% 80% Oral Surgery Extraction exposed root or erupted tooth 80% $30 70% 80% Extraction of impacted tooth soft tissue 80% $80 70% 80% Major Services* Complete upper denture 50% $500 40% 50% Partial upper denture (resin base) 50% $513 40% 50% Crown porcelain with noble metal 1 50% $488 40% 50% Pontic porcelain with noble metal 1 50% $488 40% 50% Inlay metallic (3 or more surfaces) 50% $463 40% 50% Oral Surgery Removal of impacted tooth partially bony 50% $175 40% 80% Endodontic Services Bicuspid root canal therapy 80% $195 40% 80% Molar root canal therapy 50% $445 40% 80% Periodontic Services Scaling & root planing per quadrant 80% $65 40% 80% Osseous surgery per quadrant 50% $445 40% 80% Orthodontic Services Not covered Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply See page 38 for important plan provisions. 30
Aetna Dental Plans 2 9 Option 4 PPO Max 1000 Option 5 PPO 1500 (90th) Option 6 DMO Copay 41 PPO Max Plan 100/80/50 PPO Plan 100/80/50 Office Visit Copay N/A N/A $10 Annual Deductible per Member does not apply to diagnostic & preventive services $50; 3X family maximum $50; 3X family maximum None DMO Plan 41 Annual Maximum Benefit $1,000 $1,500 Unlimited Diagnostic Services Oral Exams Periodic oral exam 100% 100% No charge Comprehensive oral exam 100% 100% No charge Problem-focused oral exam 100% 100% No charge X-rays Bitewing single film 100% 100% No charge Complete series 100% 100% No charge Preventive Services Adult cleaning 100% 100% No charge Child cleaning 100% 100% No charge Sealants per tooth 100% 100% $10 Fluoride application with cleaning 100% 100% No charge Space maintainers 100% 100% $100 Basic Services Amalgam filling 2 surfaces 80% 80% $32 Resin filling 2 surfaces, anterior 80% 80% $55 Oral Surgery Extraction exposed root or erupted tooth 80% 80% $30 Extraction of impacted tooth soft tissue 80% 80% $80 Major Services* Complete upper denture 50% 50% $500 Partial upper denture (resin base) 50% 50% $513 Crown porcelain with noble metal 1 50% 50% $488 Pontic porcelain with noble metal 1 50% 50% $488 Inlay metallic (3 or more surfaces) 50% 50% $463 Oral Surgery Removal of impacted tooth partially bony 50% 50% $175 Endodontic Services Bicuspid root canal therapy 50% 50% $195 Molar root canal therapy 50% 50% $435 Periodontic Services Scaling & root planing per quadrant 50% 50% $65 Osseous surgery per quadrant 50% 50% $445 Orthodontic Services Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply See page 38 for important plan provisions. 31
Aetna Dental Plans 2 9 Option 7 DMO Access Option 8 Aetna Dental Preventive Care Option 9 PPO Max 2000 DMO Plan 42 (DMO Access) PPO Max 100/0/0 Office Visit Copay $10 N/A N/A Annual Deductible per Member does not apply to diagnostic & preventive services PPO Max Plan 100/80/50 None None $50; 3X family maximum Annual Maximum Benefit Unlimited Unlimited $2,000 Diagnostic Services Oral Exams Periodic oral exam No charge 100% 100% Comprehensive oral exam No charge 100% 100% Problem-focused oral exam No charge 100% 100% X-rays Bitewing single film No charge 100% 100% Complete series No charge 100% 100% Preventive Services Adult cleaning No charge 100% 100% Child cleaning No charge 100% 100% Sealants per tooth $10 100% 100% Fluoride application with cleaning No charge 100% 100% Space maintainers $100 100% 100% Basic Services Amalgam filling 2 surfaces $32 Not covered 80% Resin filling 2 surfaces, anterior $55 Not covered 80% Oral Surgery Extraction exposed root or erupted tooth $30 Not covered 80% Extraction of impacted tooth soft tissue $80 Not covered 80% Major Services* Complete upper denture $500 Not covered 50% Partial upper denture (resin base) $513 Not covered 50% Crown porcelain with noble metal 1 $488 Not covered 50% Pontic porcelain with noble metal 1 $488 Not covered 50% Inlay metallic (3 or more surfaces) $463 Not covered 50% Oral Surgery Removal of impacted tooth partially bony $175** Not covered 80% Endodontic Services Bicuspid root canal therapy $195 Not covered 80% Molar root canal therapy $435** Not covered 80% Periodontic Services Scaling & root planing per quadrant $65 Not covered 80% Osseous surgery per quadrant $445** Not covered 80% Orthodontic Services Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply See page 38 for important plan provisions. 32
Aetna Voluntary Dental Plans 3 9 Voluntary Option 1 DMO Voluntary Option 2 Freedom-of-Choice Monthly selection between the DMO and PPO Max Plan Voluntary Option 3 PPO Max DMO Plan 100/80/50 DMO Plan 100/90/60 PPO Max Plan 100/70/40 Office Visit Copay $10 $10 N/A N/A Annual Deductible per Member does not apply to diagnostic & preventive services PPO Max Plan 100/80/50 None None $50; 3X family maximum $50; 3X family maximum Annual Maximum Benefit Unlimited Unlimited $1,000 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% 100% Child cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 90% 70% 80% Resin filling 2 surfaces, anterior 80% 90% 70% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 90% 70% 80% Extraction of impacted tooth soft tissue 80% 90% 70% 80% Major Services* Complete upper denture 50% 60% 40% 50% Partial upper denture (resin base) 50% 60% 40% 50% Crown porcelain with noble metal 1 50% 60% 40% 50% Pontic porcelain with noble metal 1 50% 60% 40% 50% Inlay metallic (3 or more surfaces) 50% 60% 40% 50% Oral Surgery Removal of impacted tooth partially bony 50% 60% 40% 50% Endodontic Services Bicuspid root canal therapy 80% 90% 40% 50% Molar root canal therapy 50% 60% 40% 50% Periodontic Services Scaling & root planing per quadrant 80% 90% 40% 50% Osseous surgery per quadrant 50% 60% 40% 50% Orthodontic Services Not covered Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply See page 38 for important plan provisions. 33
Aetna Voluntary Dental Plans 3 9 Option 4 DMO Copay 41 Option 5 DMO Access Option 6 Aetna Dental Preventive Care DMO Plan 41 DMO plan 42 PPO Max 100/0/0 Office Visit Copay $15 $15 N/A Annual Deductible per Member does not apply to diagnostic & preventive services None None None Annual Maximum Benefit Unlimited Unlimited Unlimited Diagnostic Services Oral Exams Periodic oral exam No charge No charge 100% Comprehensive oral exam No charge No charge 100% Problem-focused oral exam No charge No charge 100% X-rays Bitewing single film No charge No charge 100% Complete series No charge No charge 100% Preventive Services Adult cleaning No charge No charge 100% Child cleaning No charge No charge 100% Sealants per tooth $10 $10 100% Fluoride application with cleaning No charge No charge 100% Space maintainers $100 $100 100% Basic Services Amalgam filling 2 surfaces $32 $32 Not covered Resin filling 2 surfaces, anterior $55 $55 Not covered Oral Surgery Extraction exposed root or erupted tooth $30 $30 Not covered Extraction of impacted tooth soft tissue $80 $80 Not covered Major Services* Complete upper denture $500 $500 Not covered Partial upper denture (resin base) $513 $513 Not covered Crown porcelain with noble metal 1 $488 $488 Not covered Pontic porcelain with noble metal 1 $488 $488 Not covered Inlay metallic (3 or more surfaces) $463 $463 Not covered Oral Surgery Removal of impacted tooth partially bony $175 $175** Not covered Endodontic Services Bicuspid root canal therapy $195 $195 Not covered Molar root canal therapy $435 $435** Not covered Periodontic Services Scaling & root planing per quadrant $65 $65 Not covered Osseous surgery per quadrant $445 $445** Not covered Orthodontic Services Not covered Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply See page 38 for important plan provisions. 34
Aetna 10 100 Dental Plans (Standard and Voluntary) Option 1A DMO 100/80/50 Option 2A FOC PPO Max Freedom-of-Choice Monthly selection between the DMO and PPO Max DMO Plan 100/80/50 100/90/60 PPO Max Plan 100/80/50 Office Visit Copay $5 $5 N/A Annual Deductible per Member does not apply to diagnostic & preventive services None None $50; 3X family maximum Annual Maximum Benefit Unlimited Unlimited $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% Comprehensive oral exam 100% 100% 100% Problem-focused oral exam 100% 100% 100% X-rays Bitewing single film 100% 100% 100% Complete series 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% Child cleaning 100% 100% 100% Sealants per tooth 100% 100% 100% Fluoride application with cleaning 100% 100% 100% Space maintainers 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 90% 80% Resin filling 2 surfaces, anterior 80% 90% 80% Endodontic Services Bicuspid root canal therapy 80% 90% 80% Periodontic Services Scaling & root planing per quadrant 80% 90% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 90% 80% Extraction of impacted tooth soft tissue 80% 90% 80% Major Services* Complete upper denture 50% 60% 50% Partial upper denture (resin base) 50% 60% 50% Crown porcelain with noble metal 50% 60% 50% Pontic porcelain with noble metal 50% 60% 50% Inlay metallic (3 or more surfaces) 50% 60% 50% Oral Surgery Removal of impacted tooth partially bony 50% 60% 50% Endodontic Services Molar root canal therapy 50% 60% 50% Periodontic Services Osseous surgery per quadrant 50% 60% 50% Orthodontic Services* (optional for dependent children) $2,300 copay $2,300 copay 50% Orthodontic Lifetime Maximum Does not apply Does not apply $1,000 See page 39 for important plan provisions. 35
Aetna 10 100 Dental Plans (Standard and Voluntary) Option 3A FOC PPO 80th Freedom-of-Choice Monthly selection between the DMO and PPO Option 4A PPO Max 1000 Option 5A PPO Max 1500 100/90/60 PPO Plan 100/80/50 PPO Max Plan 100/80/50 Office Visit Copay $5 N/A N/A N/A Annual Deductible per Member does not apply to diagnostic & preventive services PPO Max Plan 100/80/50 None $50; 3X family maximum $50; 3X family maximum $50; 3X family maximum Annual Maximum Benefit Unlimited $1,000 $1,000 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% 100% Child cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 90% 80% 80% 80% Resin filling 2 surfaces, anterior 90% 80% 80% 80% Endodontic Services Bicuspid root canal therapy 90% 80% 80% 80% Periodontic Services Scaling & root planing per quadrant 90% 80% 80% 80% Oral Surgery Extraction exposed root or erupted tooth 90% 80% 80% 80% Extraction of impacted tooth soft tissue 90% 80% 80% 80% Major Services* Complete upper denture 60% 50% 50% 50% Partial upper denture (resin base) 60% 50% 50% 50% Crown porcelain with noble metal 60% 50% 50% 50% Pontic porcelain with noble metal 60% 50% 50% 50% Inlay metallic (3 or more surfaces) 60% 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 60% 50% 80% 80% Endodontic Services Molar root canal therapy 60% 50% 80% 80% Periodontic Services Osseous surgery per quadrant 60% 50% 80% 80% Orthodontic Services* (optional for dependent children) $2,300 copay 50% 50% 50% Orthodontic Lifetime Maximum Does not apply $1,000 $1,000 $1,000 See page 39 for important plan provisions. 36
Aetna 10 100 Dental Plans (Standard and Voluntary) Option 6A PPO Max 2000 Option 7A PPO 1000 80th Option 8A PPO 1500 90th Option 9A PPO 2000 90th PPO Max Plan 100/80/50 PPO Plan 100/80/50 PPO Plan 100/80/50 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member does not apply to diagnostic & preventive services PPO Plan 100/80/50 $50; 3X family maximum $50; 3X family maximum $50; 3X family maximum $50; 3X family maximum Annual Maximum Benefit $2,000 $1,000 $1,500 $2,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% 100% Child cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% 80% Resin filling 2 surfaces, anterior 80% 80% 80% 80% Endodontic Services Bicuspid root canal therapy 80% 80% 80% 80% Periodontic Services Scaling & root planing per quadrant 80% 80% 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% 80% Extraction of impacted tooth soft tissue 80% 80% 80% 80% Major Services* Complete upper denture 50% 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% 50% Crown porcelain with noble metal 50% 50% 50% 50% Pontic porcelain with noble metal 50% 50% 50% 50% Inlay metallic (3 or more surfaces) 50% 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 80% 80% 80% 80% Endodontic Services Molar root canal therapy 80% 80% 80% 80% Periodontic Services Osseous surgery per quadrant 80% 80% 80% 80% Orthodontic Services* (optional for dependent children) 50% 50% 50% 50% Orthodontic Lifetime Maximum $1,000 $1,000 $1,000 $1,000 See page 39 for important plan provisions. 37
Footnotes 2 9 Dental footnotes *Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any major service. Does not apply to the DMO in plan options 1, 2, 6 & 7, and the Aetna Dental Preventive Care in option 8. **Specialist procedures are not covered by the plan when performed by a participating specialist. However, the service is available to the member at a discount. Fixed dollar amounts on the DMO in plan options 1, 2, 6 & 7 are member responsibility. 1 There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures for the DMO in plan options 2, 6 & 7. Most oral surgery, endodontic and periodontic services are covered as basic services on the DMO in options 1 & 2. All oral surgery, endodontic and periodontic services are covered as basic services on the PPO in plan options 3 & 9. Plan options 2, 3, 4, 8 & 9; PPO Max nonpreferred (out-ofnetwork) coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Out-of-network plan payments are limited by geographic area on the PPO in plan option 5 to the prevailing fees at the 90 th percentile. The DMO in plan option 1, 6 & 7 can be offered with any one of the PPO plans in plan options 3 5, and 9 in a dual option package. DMO Access: Apart from the DMO network and DMO plan of benefits, members under this plan also have access to the Aetna Dental Access Network. This network provides access to providers who participate in the Aetna Dental Access Network and have agreed to charge a negotiated discounted fee. Members can access this network for any service. However, the DMO benefits do not apply in situations where the dentist participates in both the Aetna Dental Access Network and the Aetna DMO network. DMO benefits take precedence over all other discounts, including discounts through the Aetna Dental Access network. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 66. DMO frequency limitations will not apply to the following services if needed more frequently due to medical necessity: oral examinations, prophylaxis, fluoride treatments, bitewing X-rays, entire series of panoramic X-rays. 3 9 Dental footnotes (Voluntary Plans) *Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any major service. Does not apply to the DMO in Voluntary plan options 1, 2, 4 & 5 and on the PPO in Voluntary Plan option 6. **Specialist procedures are not covered by the plan when performed by a participating specialist. However, the service is available to the member at a discount. Fixed dollar amounts on the DMO in Voluntary Plan options 1, 2, 4 & 5 are member responsibility. 1 There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures for the DMO in Voluntary Plan options 4 & 5. Most oral surgery, endodontic and periodontic services are covered as basic services on the DMO in Voluntary options 1, 2. Plan options 2, 3 & 6; PPO Max nonpreferred (out-of-network) coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the coverage waiting period. DMO Access: Apart from the DMO network and DMO plan of benefits, members under this plan also have access to the Aetna Dental Access Network. This network provides access to providers who participate in the Aetna Dental Access Network and have agreed to charge a negotiated discounted fee. Members can access this network for any service. However, the DMO benefits do not apply. In situations where the dentist participates in both the Aetna Dental Access Network and the Aetna DMO network, DMO benefits take precedence over all other discounts including discounts through the Aetna Dental Access network. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. DMO frequency limitations will not apply to the following services if needed more frequently due to medical necessity: oral examinations, prophylaxis, fluoride treatments, bitewing X-rays, entire series of panoramic X-rays. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 66. 38
10 100 Dental footnotes Voluntary Plan Options: *Coverage Waiting Period applies to Voluntary PPO & PPO Max Options: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any major service including orthodontic services. Does not apply to the DMO in Voluntary Plan options 1A 3A and does not apply to standard plans. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the coverage waiting period. Standard & Voluntary Plan Options: Fixed dollar amounts on the DMO in plan options 1A 3A are member responsibility. Most oral surgery, endodontic and periodontic services are covered as basic services in options 1A 3A. All oral surgery, endodontic and periodontic services are covered as basic services on the PPO in plan options 4A, 5A & 7A. General anesthesia along with all oral surgery, endodontic and periodontic services are covered as basic services on the PPO in plan options 6A, 8A & 9A. Plan options 2A, 4A 6A; PPO Max nonpreferred (out-ofnetwork) coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Out-of-network plan payments are limited by geographic area on the PPO in plan options 3A & 7A to the prevailing fees at the 80 th percentile and plan options 8A & 9A at the 90 th percentile. The DMO in plan option 1A can be offered with any one of the PPO plans in plan options 4A 7A in a dual option package. Coverage for Implants is included as a major service on the PPO in plan options 6A & 9A. Orthodontic coverage is available only for dependent children only. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 66. DMO frequency limitations will not apply to the following services if needed more frequently due to medical necessity: oral examinations, prophylaxis, fluoride treatments, bitewing X-rays, entire series or panoramic X-rays. 39
Aetna Life & Disability Group life and disability is an affordable way to provide life insurance and disability benefits to employees that will help them establish financial protection for themselves and their families. 40
Life & Disability Overview For groups of 2 to 50, Aetna Life Insurance Company (Aetna) Small Group packaged life and disability insurance plans include a range of flat-dollar insurance options bundled together in one monthly per-employee rate. These products are easy to understand and offer affordable benefits to help your employees protect their families in the event of illness, injury or death. You ll benefit from streamlined plan installation, administration and claims processing, and all of the benefits of our stand-alone life and disability products for small groups. Or, simply choose from our portfolio of group basic term life and disability insurance plans. For groups of 51 and above, Aetna offers a robust portfolio of life and disability products with flexible plan features. Please consult your sales representative for a plan designed to meet your group s needs: Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Short-term disability Long-term disability Life insurance We know that life insurance is an important part of the benefits package you offer your employees. That s why our products and programs are designed to meet your needs for: Flexibility Added value Cost-efficiency Experienced support We help you give employees what they re looking for in lifestyle protection, through our selected group life insurance options. And we look beyond the benefits payout to include useful enhancements through the Aetna Life Essentials SM program. So what s the bottom line? A portfolio of value-packed products and programs to attract and retain workers while making the most of the benefits dollars you spend. Giving you (and your employees) what you want Employees are looking for cost-efficient plan features and value-added programs that help them make better decisions for themselves and their dependents. Our life insurance plans come with a variety of features including: Accelerated death benefit Also called the living benefit, the accelerated death benefit provides payment to terminally ill employees or spouses. This payment can be up to 75 percent of the life insurance benefit. Premium waiver provision Employee coverage may stay in effect up to age 65 without premium payments if an employee becomes permanently and totally disabled while insured due to an illness or injury prior to age 60. Optional dependent life This feature allows employees to add optional coverage for eligible spouses and children for employers with 10 or more employees. This employee-paid benefit enables employees to cover their spouses and dependent children. Our fresh approach to life With Aetna Life Essentials, your employees have access to programs during their active lives to help promote healthy, fulfilling lifestyles. In addition, Aetna Life Essentials SM provides for critical caring and support resources for often-overlooked needs during the end of one s life. And we also include value for beneficiaries and their loved ones well beyond the financial support from a death benefit. 41
AD&D Ultra AD&D Ultra is standardly included with our small group term life plans and in our packaged life and disability plans, and provides employees and their families with the same coverage as a typical accidental death and dismemberment plan and then some. This includes extra benefits at no additional cost to you, such as coverage for education or child-care expenses that make this protection even more valuable. Covered losses include: Death Dismemberment Loss of sight Loss of speech Loss of hearing Third-degree burns Paralysis Coma Total disability Exposure and disappearance Extra benefits for the following: Passenger restraint use and airbag deployment* Education assistance for dependent child and/or spouse* Child-care benefit* Repatriation of mortal remains* Integrated Health and Disability With our Integrated Health and Disability program, we can link medical and disability data to help anticipate concerns, take action and get your employees back to work sooner: Predictive modeling identifies medical members most likely to experience a disability, potentially preventing a disability from occurring or minimizing the impact for better outcomes. Health Insurance Portability and Accountability Act (HIPAA)-compliant so medical and disability staff can share clinical information and work jointly with the employee to help address medical and disability issues. Referrals between health case managers and their disability counterparts help ensure better consistency and integration. The Integrated Health and Disability program is available at no additional cost when a member has both medical and disability coverage from Aetna. For a summary list of Limitations and Exclusions, refer to pages 66-67. Disability insurance Finding disability insurance or benefits for you and your employees isn t difficult. Many companies offer them. The challenge is finding the right plan one that will meet the distinct needs of your business. Aetna understands this. Our in-depth approach to disability helps give us a clear understanding of what you and your employees need and then helps meet those needs. You ll get the right resources, the right support and the right care for your employees at the right time: Our clinically based disability model ensures claims and duration guidelines are fact-based with objective benchmarks. We offer a holistic approach that takes the whole person into account. We give you 24-hour access to claim information. We provide return-to-work programs to help ensure employees are back to work as soon as it s medically safe to do so. We employ vocational rehabilitation and ergonomic specialists who can help restore employees back to health and productive employment. Life and disability products are underwritten or administered by Aetna Life Insurance Company (Aetna). *Only available if insured loses life. 42
Term Life Plan Options 2 9 Employees 10 50 Employees Basic Life Schedule Flat $10,000, $15,000, $20,000, $50,000 Flat $10,000, $15,000, $20,000, $50,000, $75,000, $100,000, $125,000 Class Schedules Not available Up to 3 classes (with a minimum requirement of 3 employees in each class) the benefit amount of the highest class cannot be more than 5 times the benefit amount of the lowest class Premium Waiver Provision Premium Waiver 60 Premium Waiver 60 Age Reduction Schedule Original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Accelerated Death Benefit Up to 75% of life amount for terminal illness Up to 75% of life amount for terminal illness Guaranteed Issue $50,000 10-25 employees $75,000 26-50 employees $100,000 Participation Requirements 100% 100% on noncontributory plans; 75% on contributory plans Contribution Requirements 100% employer contribution Minimum 50% employer contribution AD&D Ultra AD&D Ultra Schedule Matches life benefit Matches life benefit AD&D Ultra Extra Benefits Optional Dependent Term Life Passenger restraint use and airbag deployment, education benefit for your child and/or spouse, child care and repatriation of mortal remains. Spouse Amount Not available $5,000 Child Amount Not available $2,000 Passenger restraint use and airbag deployment, education benefit for your child and/or spouse, child care and repatriation of mortal remains. For plan options for group size 51 and above, please consult your representative. Life and disability products are underwritten or administered by Aetna Life Insurance Company (Aetna). 43
Packaged Life and Disability Plan Options Plan Options 2-50 Basic Life Plan Design Low Option Low Option 2 Medium Option Medium Option 2 High Option Benefit Flat $10,000 Flat $15,000 Flat $20,000 Flat $25,000 Flat $50,000 Guaranteed Issue 2 9 Lives 10 50 Lives $10,000 $10,000 $15,000 $15,000 $20,000 $20,000 $20,000 $25,000 $20,000 $50,000 Reduction Schedule Employee s original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Employee s original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Employee s original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Employee s original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Employee s original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Disability Provision Premium Waiver 60 Premium Waiver 60 Premium Waiver 60 Premium Waiver 60 Premium Waiver 60 Conversion Included Included Included Included Included Accelerated Death Benefit Up to 75% of benefit; 24-month acceleration Up to 75% of benefit; 24-month acceleration Up to 75% of benefit; 24-month acceleration Up to 75% of benefit; 24-month acceleration Up to 75% of benefit; 24-month acceleration Dependent Life Spouse $5,000; Child $2,000 Spouse $5,000; Child $2,000 Spouse $5,000; Child $2,000 Spouse $5,000; Child $2,000 Spouse $5,000; Child $2,000 AD&D Ultra AD&D Ultra Schedule Matches basic life benefit Matches basic life benefit Matches basic life benefit Matches basic life benefit Matches basic life benefit AD&D Ultra Extra Benefits Passenger restraint use and airbag deployment, education benefit for your child and/or spouse, child care and repatriation of mortal remains. Disability Plan Design Monthly Benefit Flat $500; No offsets Flat $1,000; offsets are workers compensation, any state disability plan, and primary and family social security benefits. Elimination Period 30 days 30 days 30 days 30 days 30 days Definition of Disability Own occupation: Earnings loss of 20% or more. Own occupation: Earnings loss of 20% or more. Own occupation: Earnings loss of 20% or more. Own occupation: Earnings loss of 20% or more. First 24 months of benefits: Own occupation: Earnings loss of 20% or more; any reasonable occupation thereafter: 40% earnings loss. Benefit Duration 24 months 24 months 24 months 24 months 60 months Pre-Existing Condition Limitation 3/12 3/12 3/12 3/12 3/12 Types of Disability Occupational & non-occupational Occupational & non-occupational Occupational & non-occupational Occupational & non-occupational Occupational & non-occupational Separate Periods of Disability 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter Mental Health/Substance Abuse Duration same as all other conditions Duration same as all other conditions Duration same as all other conditions Duration same as all other conditions Duration same as all other conditions Waiver of Premium Included Included Included Included Included Other Plan Provisions Eligibility Active full-time employees Active full-time employees Active full-time employees Active full-time employees Active full-time employees Rate Guarantee 1 year 1 year 1 year 1 year 1 year Rates PEPM $8.00 $10.00 $15.00 $16.00 $27.00 For plan options for group size 51 and above, please consult your representative. Life and disability products are underwritten or administered by Aetna Life Insurance Company (Aetna). 44
Aetna Underwriting In business, nothing is more critical to success than the health and well-being of employees. 45
Underwriting guidelines This material is intended for brokers and agents and is for informational purposes only. It is not intended to be all inclusive. Other policies and guidelines may apply. Note: State and Federal Legislation/Regulations, including Small Group Reform and HIPAA, take precedence over any and all underwriting rules. Exceptions to underwriting rules require approval of the Regional Underwriting Manager. This information is the property of Aetna and its affiliates ( Aetna ), and may only be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing. Affiliated, Associated or Multiple Companies Employers who have more than one business with different tax identification numbers (TINs) may be eligible to enroll as one group if the following are met: One owner has controlling interest of all business to be included; or The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851, a combined tax return for all companies to be included. If they are eligible but choose not to file Form 851, please indicate as such. A copy of the latest filed tax return must be provided; and All businesses filed under one combined tax return must be enrolled as one group. For example, if the employer has three businesses and files all three under one combined tax return, then all three businesses must be enrolled for coverage. If the request is for only 2 of the 3 businesses to be enrolled, the group will be considered a carve-out, will not be Guarantee Issue, and could be declined. The enrolling business (the group that is being used as the policy name) as well as the other businesses to be combined must have the minimum number of employees required by the state. The 2 or more groups may have multiple Standard Industrial Classification (SIC) codes; however, rates will be based on the SIC code for the group with the majority of employees, or the highest SIC rate if equal numbers. A completed Common Ownership form is submitted. Businesses with equal controlling interest may be considered, if the owners of the company designate an individual to act on behalf of all the groups. Underwriting reserves the right to final underwriting review, and may consider common ownership on a case-by-case underwriting exception. Example One owner has controlling interest of all companies to be included: --Company 1 Jim owns 75% and Jack owns 25% --Company 2 Jim owns 55% and Jack owns 45% Both companies can be written as one group since Jim has controlling interest in both. 46
Benefit Waiting Period Case Submission Dates Census Data Deductible Credit Deductible Funding 100% plans only Benefit waiting periods must be consistently applied to all employees, including newly hired key employees. The benefit waiting period for future employees may be 0, 1, 2, 3, 4, 5 or 6 months. If the employer currently has a different waiting period, the employer may indicate this on the employer application, subject to underwriting approval. Any benefit waiting period over 6 months requires underwriting manager approval. For new hires, the eligibility date will be the first day of the policy month following the waiting period. Policy month refers to the contract effective date of the 1 st or 15 th. --Example 1 Effective date is July 1; employees will be issued an effective date of the 1 st of the month following the selected waiting period. --Example 2 Effective date is July 15, employees will be issued an effective date of the 15 th of the month following the selected waiting period. Two benefit waiting periods may be selected and must be consistently applied within a class of employees as defined by the employer. If 2 classes are elected, each class must represent a distinct group of employees (hourly vs. salaried, management vs. non-management, etc.) At initial submission of the group, the benefit waiting period may be upon the employer s request. This should be checked on the employer application and consistently applied to all employees. Changes to the benefit waiting period can only occur one time in 12 months or on the group s anniversary date. No retroactive benefit waiting period changes will be allowed. Groups with 2 to 100 eligible employees must have all completed paperwork into Aetna Underwriting no later than the end of business day following the requested effective date. If not received by this date, the effective date will be moved to the next available effective date, with potential rate impact. Any cases received after the cutoff date will be considered on an exception basis only, as approved by the Underwriting Unit Manager. Census data must be provided for all eligible employees, including enrolled, waivers, employees in the waiting period and COBRA eligible employees. Include the name, date of birth, date of hire, gender, dependent status, residence zip code and employee work location zip code. COBRA eligible employees should be included on the census and noted as COBRA. Employees who are eligible and want to receive credit for deductible paid to prior carrier should submit a copy of the Explanation of Benefits to Aetna (EOB) to Aetna no later than 90 days after the effective date. Note: this is for group-to-group takeover for individuals on the prior group plan. They may do this either at the initial small group submission or with their first claim. Plan sponsors will be asked to sign an attestation form certifying whether any underlying plan or third-party arrangement is being used to subsidize the deductible. If the attestation form is not received or indicates a funding level of 50% or greater, the group is not eligible for coverage with Aetna. 47
Dental Coverage Waiting Period Standard 2 to 9 and Voluntary 3 to 100 eligible employees PPO and Indemnity Plans for Major and Orthodontic Services employees must be an enrolled member of the employer s plan for 1 year before becoming eligible. DMO there is no waiting period. Discount plans do not qualify as previous coverage. Future hires waiting period applies regardless if takeover for Voluntary 3 to 100 eligible employees. Virgin group (no prior coverage) the waiting periods apply to employees at case inception as well as any future hires. Takeover/Replacement cases (prior coverage) you must provide a copy of the last billing statement and schedule of benefits in order to provide credit. If a group s prior coverage did not lapse more than 90 days prior, the waiting periods are. In order for the waiting period to be, the group must have had a dental plan in place that covered major (and ortho, if applicable) immediately preceding our takeover of the business. Example: Prior major coverage but no ortho coverage. Aetna plan has coverage for both major and ortho. The waiting period is for major services but not for ortho services. Standard 10 to 100 eligible employees No waiting period Open Enrollment An open enrollment is a period when any employee can elect to join the dental plan without penalty, regardless if they previously declined coverage during the first 31 days of initial eligibility. Open enrollments are prohibited except for standard plans with 10 to 100 eligible employees. For standard plans employees/dependents who do not enroll when initially eligible are now eligible to enroll during a subsequent open enrollment period without being subject to the late entrant provision. Voluntary plans and standard plans with 2 to 9 eligible employees An employee or dependent can enroll at any time but is subject to the dental late entrant provision if enrollment occurs other than within 31 days of first becoming eligible unless a qualifying life event has occurred or the enrollee is less than age 5. Option Sales Option sales alongside another dental carrier are not allowed. All dental plans must be sold on a full replacement basis. Reinstatement Voluntary plans only Members once enrolled who have previously terminated their coverage by discontinuing their contributions may not re-enroll for a period of 24 months. All coverage rules will apply from the new effective date including, but not limited to, the coverage waiting period. 48
Dependent Eligibility Eligible dependents include an employee s: Spouse. If both husband and spouse work for the same company they may enroll together or separately. If enrolling together, rates will be based on the oldest adult. Domestic Partner is an eligible dependent, however, the employer must choose to cover domestic partners at initial underwriting of the group. If not done at time of enrollment, approval of future request to add coverage for domestic partners will be postponed until the group s next anniversary date. Children Medical and Dental --Children are eligible as defined in plan documents in accordance with state and federal law, are eligible for medical and dental coverage up to age 26, regardless of financial dependency, employment, eligibility of other coverage, student status, marital status, tax dependency or residency. This requirement applies to natural and adopted children, stepchildren, and children subject to legal guardianship. --Children eligible for coverage through both parents cannot be covered by both parents under the same plan. --When the child works for the same company as the parent, the child may enroll separately as an employee OR as a dependent under the parent s plan. --Grandchildren are eligible if court-ordered. A copy of the court papers must be submitted. --Incapacitated child: Attainment of limiting age will not terminate the coverage of the child while the child is, and continues to be, both incapable of self-sustaining employment by reason of mental retardation or physical handicap and chiefly dependent upon the employee or member for support and maintenance. Proof of incapacity and dependency shall be furnished to Aetna by the employee or the member within 31 days of the child s attainment of the limiting age and subsequently as may be required by Aetna, but not more frequently than annually after the two-year period following the child s attainment of the limiting age. Life --2 to 50 eligible employees dependents are eligible from 14 days of age up to their 19 th birthday, or up to their 23 rd birthday if in school. --51 to 100 eligible employees contact your Aetna Account Executive AD&D or Disability --2 to 50 eligible employees dependents are not eligible for AD&D or Disability coverage. --51 to 100 eligible employees contact your Aetna Account Executive. Dependents must enroll in the same benefits as the employee (participation is not required). Employees may select coverage for eligible dependents under the dental plan even if they select single coverage under the medical plan. Individuals cannot be covered as an employee and dependent under the same plan Effective Date Electronic Funds Transfer (EFT)/ACH The effective date must be the 1 st or the 15 th of the month. The effective date requested by the employer may be up to 60 days in advance. When replacing an employer-sponsored group plan, the effective date must coincide with the premium date of the other carrier, without regard to the grace period. For example, if the other plan has a premium date of the 1 st, the Aetna plan will be effective on the 1 st and not the 15 th. Payment for the first month s premium at new business can be processed via an electronic funds transfer (EFT)/ACH. Once the group is issued coverage, customers can pay their monthly premiums online or by calling an automated phone number, 1-866-350-7644, using their checking account and routing number. There is no extra charge for this service. 49
Employee Eligibility 2 to 50 Group Size Unless otherwise specified by the employer, we will use this industry standard employee eligibility criteria definition: --An employee who works for a small employer on a full-time basis with a normal work week of 25 hours or more. --If the employer s employee eligibility criteria differ from the above criteria (less than 25 hours), the employer s actual definition must be provided on the employer application at the time of new business submission, subject to underwriting approval. --Union employees, even if currently covered under the union plan. --Partners, proprietors. Eligible employees will NOT include part-time, temporary employees, seasonal employees, substitute employees, independent contractors (1099), uncompensated employees, employees making less than equivalent minimum wage, volunteers, retirees, inactive owners, officers who are not active, managing members who are not active, investors or shareholders who are not otherwise eligible and silent partners. Life and Disability Only: Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day. Retirees 2 to 50 eligible employees not eligible. 51 to 100 eligible employees --Retirees cannot comprise more than 10% of the group. --The retiree must be currently covered with present carrier (must be shown on the bill roster or provide a copy of the ID card). --If there were no retirees covered by the prior carrier the employee must be covered as an employee on the bill roster. Medicare eligible retirees who are enrolled in an Aetna Medicare plan are eligible to enroll in standard dental plans in accordance with these dental underwriting guidelines. Retirees are not eligible for life, disability or voluntary dental coverage. COBRA COBRA coverage will be extended in accordance with the federal legislation/regulations. COBRA continuees are not eligible for life or disability coverage. COBRA continuees are included in the medical underwriting of the group. Health information must be provided on COBRA continuees, along with the rest of the group. Eligible enrollees are required to be included on the census. 51 to 100 size groups: COBRA continuees can not comprise more than 10% of the total eligible. COBRA qualifying event, length, start and end date must be provided. Employers with 20 or more employees (full and part time) are eligible to offer COBRA coverage. 50
Employer Eligibility Small group employer means an employer who employs at least 2 but no more than 50 eligible employees on a typical business day during any one calendar year. Groups with 2 to 50 eligible employees that do not meet the above definition of a small employer are not eligible for coverage. Groups with 51 to 100 eligible employees are not subject to Small Group Reform (SGR) and are therefore not Guaranteed Issue and may be declined. Carve outs are not allowed. All Aetna plans can be offered to sole proprietors, partnerships or corporations. Employers (companies/organizations) must not be formed solely for the purpose of obtaining health coverage. Non-guaranteed associations, Taft-Hartley groups, professional employer organizations (PEOs)/employee leasing firms, closed groups (groups that restrict eligibility through criteria other than employment) and groups where no employee/employer relationship exists are not eligible for small group coverage. Dental and life products have ineligible industries, which are listed separately under Product Specifications. The dental- and life-ineligible industry list does not apply when dental or life is sold in combination with medical. Newly Formed Businesses For groups of 2 to 50 eligible employees, the following documentation must be provided for consideration: Sole Proprietor Partnership or Limited Liability Partnership Limited Liability Company A copy of the Business License (not a professional license) A copy of the Partnership Agreement A copy of the Articles of Organization and the Operating Agreement to include the signature page(s) of all officers Corporation Each newly formed business must also provide: A copy of the Articles of Incorporation that includes the signature page(s) of all officers (must be followed up with a copy of the Statement of Information within 30 days of filing with the State) Proof of employer identification number/federal tax I.D. number (Social Security number if sole proprietorship); and A copy of the UC018/UC020 (Quarterly Wage and Tax Statement); if not available, must provide the most recent 2 consecutive weeks worth of payroll records, which includes, for every eligible employee: first and last name, hours worked, taxes withheld, SSN or last 4 digits, check number, wages earned including those PT or in the WP; or A letter from a CPA with the following information if a QWTS or payroll records are not available: --A list of all employees, to include owners, partners, officers (full time and part time) --Number of hours worked by each employee --Weekly salary for each employee --Date of hire for each employee --Whether payroll records have been established --If a Quarterly Wage and Tax Statement UC018/UC020 is filed and, if so, when 51
Employers leaving an Aetna PEO Initial Premium As long as the PEO provides payroll specific for the small group and we can determine it is a small group, even though the small group may be reported under the PEO tax ID number, the group may be considered subject to underwriting approval. The first month s premium may be submitted in the form of a check or electronic funds transfer. Either submit a copy of the initial premium check payable to Aetna Inc. or complete the EFT/ACH form (Aetna Form). If the EFT/ACH method is selected, we will withdraw the first initial premium from the checking account when the group is approved. This is a one time authorization for the first month premium only. If a copy of the check is provided, once coverage is approved you will be advised where to mail the initial premium check. The initial premium check is not a binder check. Final premium will be determined upon underwriting review. If the request for coverage is withdrawn or denied due to business ineligibility, participation and/or contributions not met, the premium will not be processed and the check will be returned to the employer. If the initial premium check is returned due to insufficient funds, coverage will be terminated retroactive to the effective date. 52
Life - Basic Term Job Classification (Position) Schedules Varying levels of coverage based on job classifications are available for groups with 10 or more lives. Up to three separate classes are allowed (with a minimum requirement of 3 employees in each class). Items such as probationary periods must be applied consistently within a class of employee. The benefit for the class with the richest benefit must not be greater than five times the benefit of the class with the lowest benefit. For example, a schedule may be structured as follows: Position/Job Class Basic Term Life Amount Packaged Life & Disability Executives $50,000 High Option Managers, Supervisors $20,000 Medium Option All other employees $10,000 Low Option Guaranteed Issue Coverage Aetna provides certain amounts of life insurance to all timely entrants without requiring an employee to answer any medical questions. These insurance amounts are called Guaranteed Issue. Employees wishing to obtain increased insurance amounts will be required to submit evidence of insurability, which means they must complete a medical questionnaire and may be required to provide medical records. On-time enrollees who do not meet the requirements for evidence of insurability will receive the Guaranteed Issue Life amount. Case Size Basic Term Life 2 to 9 eligible lives $50,000 10 to 25 eligible lives $75,000 26 to 50 eligible lives $100,000 Late enrollees must qualify for the entire amount and are not guaranteed any coverage. Actively at work Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day. Continuity of Coverage (no loss/no gain) The employee will not lose coverage due to a change in carriers. This protects employees who are not actively at work during a change in insurance carriers. If an employee is not actively at work, Aetna will waive the actively-at-work requirement and provide coverage, except no benefits are payable if the prior plan is liable. 53
Life - Basic Term (continued) Evidence of Insurability (EOI) EOI is required when one or more of the following conditions exist: 1. Life insurance coverage amounts requested are above the guaranteed standard issue limit. 2. Late entrant Coverage is not requested within 31 days of eligibility for contributory coverage. 3. New coverage is requested during the anniversary period. 4. Coverage is requested outside of the employer s anniversary period due to qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) 5. Reinstatement or restoration of coverage is requested. 6. Dependent coverage option was initially refused by employee but requested later. The dependent would be considered a late entrant and subject to EOI, and may be declined for medical reasons. 7. Requesting life or disability at the individual level and they are a late enrollee even if enrolling on the case anniversary date. Late enrollees are not eligible for the guarantee issue limit. Example: Group has $75,000 life with $50,000 guarantee issue limit. Late enrollee enrolling for $75,000 would not automatically get the $50,000. Since the applicant is late, they must medically qualify for the entire $75,000. Open Enrollments Prohibited Live/Work Guidelines Mental Health Parity and Addiction Equity Act (MHPAEA) Employees enrolled in medical or dental who reside in a non-hmo/hno and/or DMO network code may enroll in an HMO/DMO product offered by their employer if they live within a 30-mile radius of their work site that is within the HMO/DMO service area. Product availability for group benefit offerings is always determined by the zip code of the employer. If the employee resides at a distance farther than the 30-mile radius, exception requests should be directed to Underwriting for a feasibility determination. Employees who are enrolling using the Live/Work Guidelines should include their home address and zip code as well as the work site address and zip code. All correspondence will be mailed to the employee s home address as listed on the application. If the employer employed an average of 51 or MORE total employees (including part-time and seasonal employees) during the preceding calendar year, the plan DOES NOT qualify for the MHPAEA small employer exemption and your plan IS SUBJECT to MHPAEA. If the employer employed an average of 50 or FEWER total employees (including part-time and seasonal employees) during the preceding calendar year, the plan DOES qualify for the MHPAEA small employer exemption and your plan is NOT SUBJECT to MHPAEA. Does your plan qualify for the small employer exemption under Federal Mental Health Parity? Yes means the employer is exempt and is not required to offer MHP, thus MHP does NOT apply. No means MHP does apply. Plan sponsors should consult with legal counsel to determine their status under the mental health parity law. 54
Pick-A-Plan 3 and ValuePick Rate Structure Groups of 2 to 4 enrolled employees can enroll in a single or dual option. Groups of 5 or more enrolled employees can enroll in a single, dual or triple option. Employer must contribute 50% of the employee-only rate of whichever plan the employee selects. The plans are based upon the full census of the group so actual enrollment in each plan will not cause the rates to change, however if the sold case has a different overall census than the quote, it will need to be re-rated. Pick-A-Plan 3 must have 5 or more enrolled and any combination of plans can be select. One eligible employee must enroll in each plan and remain enrolled in each plan for it to remain active at renewal. Tabular Rate Structure Employers with 2 to 9 enrolling employees will be tabular rated. All rates are based upon the employer zip code. Composite Rate Structure Employers with 10 to 100 enrolling employees will be composite rated (minimum of 10 in state enrolling). Replacing Other Group Coverage Signature Dates Spin Off Groups (current Aetna customers leaving an Aetna group only) 2 to 100 group size A copy of the most recent billing statement that includes the employee listing must be submitted. Submit all pages of the bill. The employer should be told not to cancel any existing medical coverage until they have been notified of approval from the Aetna Underwriting unit. The Aetna Employer Application and all employee applications must be signed and dated prior to and within ninety (90) days of the requested effective date. All employee applications must be completed by the employee himself/herself. Aetna will consider the group guarantee issue with the following, subject to underwriting approval: A letter from the group or broker indicating the group is enrolling as a spin off. The letter needs to include the name of the group they are spinning off from. Ownership documents showing that the spin off company is a newly formed separate entity. A minimum of 2 weeks payroll. If the group that is spinning off has been in business longer than 2 weeks, payroll will be required for the amount of time in business up to a maximum of 6 consecutive weeks. Medical claims will be reviewed along with the health information included on the employee application and included in the overall medical assessment of the group. 55
Tax Information/ Documents for Groups with 2 to 50 Eligible Employees Groups with 2 to 50 eligible employees must provide a copy of the most recent Quarterly Wage and Tax Statement (QWTS) containing the names, salaries, etc., of all employees of the employer group. --Newly hired employees should be written in on the Quarterly Wage & Tax Statement. The underwriter may request payroll in questionable situations. --Employees who have terminated or work part-time must be noted accordingly on the QWTS. --Reconciled QWTS must be signed and dated by the employer. Any hand written comments added to the QWTS must be signed and dated by the employer. The underwriter may request payroll in questionable situations. If a QWTS is not available, explain why and provide a copy of payroll records. Churches must provide Form 941, including a copy of the payroll records with employee names, wages and hours, which must match the totals on Form 941. Sole proprietors, partners or officers of the business who do not appear on the QWTS should submit one of the following identified documents. This list is not all-inclusive. The employer may provide any other documentation to establish eligibility. Sole Proprietor Franchise Limited Liability Company (operating as a Sole Proprietor) Partner Partnership Limited Liability Partnership Corporate Officer Limited Liability Company (operating as C Corp) C-Corporation Personal Service Corporation S-Corporation IRS Form 1040, along with Schedule C (Form 1040) IRS Form 1040, along with Schedule SE (Form 1040) IRS Form 1040, along with Schedule F (Form 1040) IRS Form 1040, along with Schedule K-1 (Form 1065) Any other documentation the owner would like to provide to determine eligibility IRS Form 1065 Schedule K-1 IRS Form 1120 S Schedule K-1, along with Schedule E (Form 1040) Partnership agreement, if established within 2 years Eligible partners must be listed on agreement Any other documentation the owner would like to provide to determine eligibility IRS Form 1120 S Schedule K-1, along with Schedule E (Form 1040) IRS Form 1120 W (C-Corp & Personal Service Corp) 1040 ES (Estimated Tax) (S-Corp) IRS Form 8832 (Entity classification as a corporation) W2 Articles of Incorporation, if established within 2 years Corporate officers must be listed Any other documentation the owner would like to provide to determine eligibility Tax Information/ Documents for Groups with 2 to 50 Enrolled Employees WITH Prior GROUP Coverage A QWTS is not needed if a bill roster is provided and at least 75% of the enrolled employees are on the prior carrier billing statement. A copy of the current billing statement that includes the account summary and employee roster is needed. If no prior carrier, then a QWTS is needed and documented as noted above. If a QWTS or Prior Carrier Bill Roster is not available, explain why and provide a copy of payroll records. The underwriter may request additional information if warranted. 56
Product Specifications Medical Dental Life/AD&D and Packaged Life & Disability Product Availability Groups of 100 or fewer eligible employees. May be written standalone or with ancillary coverage as noted in the following columns. Only non-occupational injuries and disease will be covered. 1 life Not available 2 eligible employees Standard dental available with medical 3 to 100 eligible employees Standard and voluntary plans available Life 1 life not available 2 to 9 eligible employees if packaged with medical 10 to 50 eligible employees if packaged with medical or dental 26 to 50 eligible employees on a stand alone basis Stand alone available. Standalone dental has ineligible Industries which are listed separately under the SIC code section of the guidelines. Orthodontic coverage Available to dependent children only for groups of 10 or more eligible employees with a minimum of 5 enrolled employees for both standard and voluntary plans. 51 to 100 contact your Aetna account executive Packaged Life and Disability 2 to 50 eligible employees if packaged with medical 26 to 50 eligible employees on a stand alone basis 51 to 100 eligible employees not available A plan sponsor cannot purchase both life and packaged life and disability plans. Product packaging rule is a group level requirement. Employees will be able to individually elect life, disability or packaged life & disability insurance even if they do not elect medical coverage. Excluded Class/Carve Outs 2 to 50 eligible employees allowed Union employees if packaged with medical Union employees if packaged with medical 51 to 100 eligible employees not allowed. All full-time employees must be considered eligible for coverage. 57
Product Specifications Medical Dental Life/AD&D and Packaged Life & Disability Employer Contribution Single-choice medical The employer must contribute at least 50% of the employee rate. Pick-A-Plan 3 (medical) The employer must contribute 50% of the employee-only rate of whichever plan the employee selects. The employer may choose to offer a defined contribution of at least $120 or the actual cost of the plan chosen, whichever is less. All Coverage can be denied based on inadequate contributions. Standard with Medical or Standalone 2 to 50 eligible employees Employer must contribute at least 25% of the total cost of the plan or 50% of the cost of employee only coverage. 51 to 100 eligible employees Employer must contribute. Excludes employee pay all plans. Voluntary with Medical or Standalone Employee pay all plans are allowed. 3 to 50 eligible employees Employer can contribute up to 25% of the total cost or 50% of the cost of employee only coverage. 2 to 9 eligible employees 100% of the total cost of the Basic Term Life plan. 10 to 50 eligible employees At least 50% of the total cost (excluding Optional Dependent Term Life). 51 to 100 eligible employees contact your Aetna account executive. Coverage can be denied based on inadequate contributions. 51 to 100 eligible employees The employer can not contribute to the cost of the employee rate. Standard and Voluntary Coverage can be denied based on inadequate contributions. 58
Product Specifications Medical Dental Life/AD&D and Packaged Life & Disability Late Applicants An employee or dependent who enrolls for coverage more than 31 days from the date first eligible is considered a late enrollee. Applicants without a qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are subject to the late entrant guidelines as noted below. Voluntary cancellation of coverage is NOT a qualifying event. For example, if a spouse is covered through his/her employer and voluntarily cancels the coverage, it is not a qualifying event to be added to the other spouse s plan. The spouse who cancelled the coverage must wait until the next plan anniversary date to be eligible to be added. Late applicants without a qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are not allowed and will be deferred to the next plan anniversary date of the group and must reapply for coverage 30 days prior to the group anniversary date. An employee or dependent may enroll at any time, however, coverage is limited to preventive & diagnostic services for the first 12 months. No coverage for most basic and major services for first 12 months (24 months for orthodontics). Late entrant provision does not apply to enrollees less than age 5. Late applicants will be deferred to the next plan anniversary date of the group and may reapply for coverage 30 days prior to the anniversary date. The applicant will be required to complete an individual health statement/ questionnaire and provide evidence of insurability (EOI). Life late enrollee example: Group has $50,000 life with $20,000 guarantee issue limit. Late enrollee enrolling for $50,000 would not automatically get the $20,000. Since the applicant is late, he/she must medically qualify for the entire $50,000. Medical Underwriting 2 to 50: An Arizona small employer subject to guaranteed issue cannot be declined based on medical conditions or claims experience; however, group rates will be adjusted for medical conditions of eligible employees and/or COBRA enrollees. This rate will range from a 1.00 RAF to a 4.00 RAF (risk adjustment factor). 2 to 25: All eligible enrollees are required to complete the Arizona Uniform Employee Health Status questionnaire. Failure to do so may result in a maximum 4.00 RAF determination. Not applicable All timely entrants will be issued the guaranteed issue amount unless reinstatement or restoration of coverage is requested. Employees wishing to obtain insurance amounts above the guaranteed issue amounts listed below will be required to submit EOI, which means they must complete an individual health statement and may have to submit to medical evidence via medical records at their expense. 51 to 100: contact your Aetna Account Executive 59
Product Specifications Medical Dental Life/AD&D and Packaged Life & Disability Medical Underwriting (continued) 26 to 100: Employers of groups with 26 to 100 eligible employees and a minimum of 20 enrolling employees applying for medical coverage are required to complete the Group Medical Questionnaire. This will apply to medical coverage only. COBRA continuees do not count to the number eligible or the number enrolled. Waiver: Eligible employees must complete sections C and I of the employee application, along with their date of hire for either the employee and/or their dependents when declining coverage. The medical questionnaire does not need to be completed for those individuals who are declining medical or life at the guaranteed issue amount. Out-of-state: Employees residing outside the state cannot be denied based on medical conditions; however, may have rates adjusted to the maximum allowed in that state. Claims: Medical claims may be reviewed for any individuals who had prior Aetna coverage and used along with the health information included on the employee application(s) and/ or Group Medical Questionnaire, and included in the overall medical assessment of the group. Option Sales Must meet participation rules. Other insurance offered by the same employer is not a valid waiver. All dental plans must be offered on a full-replacement basis. No other employer-sponsored dental plan can be offered. Must be written on a full or primary replacement basis. 60
Product Specifications Medical Dental Life/AD&D and Packaged Life & Disability Out-of-State employees Out-of-state employees who reside in an out-of-state PPO network will receive the Arizona-standard PPO product (inclusive of any required extraterritorial benefits). Members who reside out of state (OOS) will receive the same plan as in-state members (based on state rules and network availability). This applies to DMO, PPO and FOC Dental Plans. Employees are eligible for basic term life and packaged life/disability. Out-of-state employees who do not reside in an out-of-state PPO network area will receive the Arizona standard indemnity products (inclusive of any required extraterritorial benefits). If an OOS member resides in a state that does not allow the in-state plan, those members will be placed into an available PPO or indemnity plan. HMO, HNO, Savings Plus and Aetna Whole Health network plans are not allowed outside of Arizona. Network availability for out-of-state employees No indemnity or PPO products are available in HI or VT. Out-of-state employees residing in LA are required to have a separate plan quoted and sold based on LA rates and benefits. These employees are still underwritten as part of the group; however, the plans and rates for the LA members will not be based on where the employer is located. This will require a Louisiana master application and employee application to be completed. Out of Area Within Arizona Employees residing outside of an Arizona Aetna Network Service Area must enroll in either the Arizona PPO or the Aetna indemnity plan. The Aetna indemnity plan is only available if the employee resides outside of both the Arizona Aetna PPO network service area and the Arizona Aetna HMO network service area. Employees residing outside of an Arizona Aetna network service area. Employees who reside within Arizona but outside of a DMO service area may be offered an in-state PPO plan. Not applicable. 61
Product Specifications Medical Participation Noncontributory plans 100% participation is required. All employees, excluding those with coverage through another employer s plan, must enroll. 2 to 3 eligible employees 100% of eligible employees, excluding those with coverage through another employer s plan, must participate. 4 to 50 eligible employees 75% of eligible employees, excluding those with coverage through another employer s plan, must participate. 51 to 100 eligible employees 75% participation is required, excluding those with coverage through another employer s plan, and a minimum of 50% of total eligible employees must enroll. Pick-A-Plan 3 75% participation, with a minimum of 5 enrolled. 2 to 100 Size Groups All employees waiving coverage must complete the waiver section. Dependent participation is not required. Coverage can be denied based on inadequate participation. Dental For noncontributory plans 100% participation is required, excluding those with other qualifying dental coverage. Standard with medical or standalone 2 to 3 eligible employees 100% participation is required excluding those with other qualifying dental coverage. Example: 3 eligibles, 1 spousal dental 3 minus 1 = 2 x 100% = 2 must enroll 4 to 50 eligible employees 75% participation is required excluding those with other qualifying dental coverage. A minimum of 50% of total eligible employees must enroll in the dental plan. 51 to 100 eligible employees 30% participation of total eligible employees excluding those with other qualifying dental coverage. Voluntary with Medical or Standalone 3-100 eligible employees 30% excluding valid waivers. If a group does not qualify for a standard plan and has 30% or more participation, then the group qualifies for voluntary. Voluntary with Medical and Standalone Employees may select coverage for eligible dependents under the dental plan even if they elected single coverage on the medical plan or vice versa. Coverage can be denied based on inadequate participation. Life/AD&D and Packaged Life & Disability Noncontributory plans 100% participation is required. Contributory plans 2 to 9 eligible employees 100% participation is required. 10 to 50 eligible employees 75% participation is required. 51 to 100 eligible employees Contact your Aetna Account Executive Standalone life 26 to 50 eligible employees 75% participation is required. 51 to 100 eligible employees Contact your Aetna Account Executive. All plans COBRA continuees are not eligible for Life. Retirees are not eligible. Employees may elect life insurance even if they do not elect medical coverage and the group must meet the required participation percentage. If not, then life will be declined for the group. Example: 9 employees 3 waiving medical 9 must enroll for life Coverage can be denied based on inadequate participation. 62
Product Specifications Medical Dental Life/AD&D and Packaged Life & Disability Plan Changes In addition to a plan change at renewal, an upgrade in benefits may be requested once in a 12-month period. A request for downgrade in benefits may be requested twice in a 12-month period. Upgrades are subject to underwriting review. Benefit changes are not allowed during the 4 months preceding the group s renewal date. High-deductible health plans (HDHPs) The 4-month limitation may be if the group requests to add one of the HDHPs and is subject to underwriting approval. On Renewal Request must be submitted on or before the effective date of the renewal. Off Renewal Request must be submitted two weeks before the requested effective date. The future renewal date of the ancillary products will be the same as the medical plan renewal date. Requests for plan changes to be effective on the renewal date must be submitted prior to the renewal date. The effective date for the plan change will be based upon notification receipt (this will be the date the e-mail or fax was sent to Aetna). Employers may request plan changes up to the renewal date for changes that are to be effective on the renewal date. Employers must request plan changes distinct from the renewal date at least 2 weeks prior to the desired effective date. The future renewal date of the ancillary products will be the same. The requests for changes must be submitted to Aetna Small Group Underwriting 30 days prior to the requested effective date. Late requests will be moved to the next applicable effective date pending underwriting approval. Requests for plan changes to be effective on the renewal date must be submitted prior to the renewal date. Requests for plan changes at renewal should be received 10 business days prior to the renewal date. Requests for plan changes off-renewal, should be requested 60 days prior to the effective date. The effective date for the plan change will be based upon notification receipt (this will be the date the e-mail or fax was sent to Aetna). 63
Product Specifications Medical Dental Life/AD&D and Packaged Life & Disability Rate Guarantee Medical rates are guaranteed for 1 year (12 months). Dental rates are guaranteed for 1 year (12 months) unless the anniversary date of the dental is different than the medical. If the dental product is added off the original medical anniversary date, this does not apply. Life rates are guaranteed for 2 years (24 months). Standard Industrial Classification Code (SIC) Underwriting will use a variety of tools, including Dun & Bradstreet, to verify a group s industry code and classify the business correctly. 2 to 50 all industries are eligible 51 to 100 contact your Aetna Account Executive to verify SIC code eligibility All industries are eligible if sold with medical. The following industries are not eligible when dental is sold standalone or packaged only with life. 7933-7933 Bowling Centers 8611-8611 Business Associations 7911-7911 Dance Studios, Schools 7361-7363 Employment Agencies 7999-7999 Miscellaneous Amusement/ Recreation 8699-8699 Miscellaneous Membership Org 8999-8999 Miscellaneous Services 7991-7991 Physical Fitness Facilities 8811-8811 Private Households 8621-8651 Professional Membership Organizations, Labor Unions, Civic Social and Fraternal Orgs, Political Orgs 7941-7948 Professional Sports Clubs & Producers, Race Tracks 7992-7997 Public Golf Courses, Amusements, Membership Sports & Recreation Clubs 8661-8661 Religious Organizations 7922-7929 Theatrical Producers, Bands, Orchestras, Actors 2 to 9 all industries are eligible if sold with medical. 10 to 50 all industries are eligible if sold with medical or dental. 26 to 50 the following industries are not eligible when life is sold standalone. 51 to 100 contact your Aetna Account Executive. 3291-3292 Asbestos Products 7500-7599 Automotive Repairs/ Services 8010-8043 Doctors Offices Clinics 2892-2899 Explosives, Bombs & Pyrotechnics 3480-3489 Fire Arms & Ammunition 5921-5921 Liquor Stores 8600-8699 Membership Associations 1000-1499 Mining 7800-7999 Motion Picture/ Amusement & Recreation 9999-9999 Non-classified Establishments 3310-3329 Primary Metal Industries 6531-6531 Real Estate Agents 6211-6211 Security Brokers 7381-7381 Service Detective Services 8800-8899 Service Private Household 64
Limitations & exclusions These plans do not cover all health care expenses and include exclusions and limitations. Employers and members should refer to their plan documents to determine which health care services are covered and to what extent. Medical These plans do not cover all health care expenses and include exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, the plan documents may contain exceptions to this list based on state mandates or the plan design purchased. Aetna HMO & HNO All medical and hospital services not specifically covered or that are limited or excluded by the plan documents, including costs of services before coverage begins and after coverage terminates Blood and blood by-products, except as administered on an inpatient or emergency care basis Cosmetic surgery Custodial care Dental care and dental X-rays Donor egg retrieval Experimental and investigational procedures (except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial) Hearing aids Home births Implantable drugs and certain injectable drugs, including injectable infertility drugs Infertility services, including artificial insemination and advanced reproductive technologies, such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in the plan documents Long-term rehabilitation Nonmedically necessary services or supplies Orthotics, except diabetic orthotics Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider, and over-the-counter medications (except as provided in a hospital) and supplies Radial keratotomy or related procedures Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling or prescription drugs Special duty nursing Therapy or rehabilitation, other than those listed as covered Treatment of behavioral disorders Weight-control services, including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions Aetna PPO & indemnity All medical or hospital services that are not specifically covered or that are limited or excluded in the plan documents Charges related to any eye surgery, mainly to correct refractive errors Cosmetic surgery, including breast reduction Custodial care Dental care and X-rays Donor egg retrieval Experimental and investigational procedures Hearing aids Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies, such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in the plan documents Nonmedically necessary services or supplies Orthotics, as specified in the plan Over-the-counter medications and supplies Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies and counseling Special-duty nursing Weight-control services, including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions 65
Aetna HNO, PPO, indemnity, Savings Plus and Aetna Whole Health: Pre-existing conditions exclusion provision These plans impose a pre-existing conditions exclusion, which may be in some circumstances (that is, creditable coverage) and may not be applicable to you. A pre-existing conditions exclusion means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within 6 months. Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the 6-month period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 12 months from your first day of coverage or, if you were in a waiting period, from the first day of your waiting period. If you had less than 6 months of creditable coverage immediately before the date you enrolled, your plan s pre-existing conditions exclusion period will be reduced by the amount (that is, number of days) of that prior coverage. In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any certificates of creditable coverage you may have. Please contact your Aetna Member Services representative at 1-888-802-3862 for PPO and 1-888-702-3862 for HMO if you need assistance in obtaining a certificate of creditable coverage from your prior carrier or if you have any questions about the information noted above. Pre-existing condition exclusion provisions are for any individual under the age of 19 and do not apply to pregnancy. Note: For late enrollees, coverage will be delayed until the plan s next open enrollment; if applicable, the pre-existing exclusion will be applied from the individual s effective date of coverage. Dental, AD&D Ultra and Disability The Dental, AD&D Ultra and Disability plans include limitations, exclusions and charges or services that these plans do not cover. For a complete listing of all limitations and exclusions or charges and services that are not covered, please refer to your Aetna group plan documents. Limitations, exclusions and charges or services may vary by state or group size. Dental Listed below are some of the charges and services for which these dental plans do not provide coverage. For a complete list of exclusions and limitations, refer to the plan documents. Dental services or supplies that are primarily used to alter, improve or enhance appearance Experimental services, supplies or procedures Treatment of any jaw joint disorder, such as temporomandibular joint disorder Replacement of lost, missing or stolen appliances and certain damaged appliances Those services that Aetna defines as not necessary for the diagnosis, care or treatment of a condition involved Specific service limitations: --DMO plans: Oral exams (4 per year)* --PPO plans: Oral exams (2 routine and 2 problem-focused per year) --All plans: --Bitewing X-rays (1 set per year)* --Complete series X-rays (1 set every 3 years)* --Cleanings (2 per year)* --Fluoride treatments (1 per year; children under 16) --Sealants (1 treatment per tooth, every 3 years on permanent molars; children under 16)* --Scaling and root planing (4 quadrants every 2 years) --Osseous surgery (1 per quadrant every 3 years) All other limitations and exclusions in the plan documents 66 * The frequent calendar year limits for these services will not apply to the DMO plans if they are needed more frequently due to medical necessity.
Employee and Dependent Life Insurance The plan may not pay a benefit for deaths caused by suicide, while sane or insane, or from an intentionally self-inflicted injury, within two years from the effective date of the person s coverage. If death occurs after two years of the effective date but within two years of the date that any increase in coverage becomes effective, no death benefit will be payable for any such increased amount. AD&D Ultra Not all events which may be ruled accidental are covered by this plan. No benefits are payable for a loss caused or contributed to by: Air or space travel. This does not apply if a person is a passenger, with no duties at all, on an aircraft being used only to carry passengers (with or without cargo) Bodily or mental infirmity Commission of or attempting to commit a criminal act Illness, ptomaine or bacterial infection* Inhalation of poisonous gases Intended or accidental contact with nuclear or atomic energy by explosion and/or release Ligature strangulation resulting from autoerotic asphyxiation Intentionally self-inflicted injury Medical or surgical treatment* Third-degree burns resulting from sunburn Use of alcohol Use of drugs, except as prescribed by a physician Use of intoxicants Use of alcohol or intoxicants or drugs while operating any form of a motor vehicle whether or not registered for land, air or water use. A motor vehicle accident will be deemed to be caused by the use of alcohol, intoxicants or drugs if it is determined that at the time of the accident you or your covered dependent were: - Operating the motor vehicle while under the influence of alcohol at a level which meets or exceeds the level at which intoxication would be presumed under the laws of the state where the accident occurred. If the accident occurs outside of the United States, intoxication will be presumed if the person s blood alcohol level meets or exceeds.08 grams per deciliter; or - Operating the motor vehicle while under the influence of an intoxicant or illegal drug; or - Operating the motor vehicle while under the influence of a prescription drug in excess of the amount prescribed by the physician; or - Operating the motor vehicle while under the influence of an over-the-counter medication taken in an amount above the dosage instructions. Suicide or attempted suicide (while sane or insane) War or any act of war (declared or not declared) Disability Disability coverage also does not cover any disability that: Is due to an occupational illness or occupational injury except in the case of sole proprietors or partners who cannot be covered by workers compensation Is due to insurrection, rebellion, or taking part in a riot or civil commotion Is due to intentionally self-inflicted injury (while sane or insane) Is due to war or any act of war (declared or not declared) Results from your commission of, or attempting to commit a criminal act Results from a motor vehicle accident caused by operating the vehicle while you are under the influence of alcohol. A motor vehicle accident will be deemed to be caused by the use of alcohol if it is determined that at the time of the accident you were operating the motor vehicle while under the influence of alcohol at a level which meets or exceeds the level at which intoxication would be presumed under the laws of the state where the accident occurred. If the accident occurs outside of the United States, intoxication will be presumed if the person s blood alcohol level meets or exceeds.08 grams per deciliter. Disability coverage does not cover any disability on any day that you are confined in a penal or correctional institution for conviction of a criminal act or other public offense. You will not be considered to be disabled, and no benefits will be payable. No benefit is payable for any disability that occurs during the first 12 months of coverage and is due to a pre-existing condition for which the member was diagnosed, treated or received services, treatment, drugs or medicines three months prior to the coverage effective date. * These do not apply if the loss is caused by: - An infection which results directly from the injury. - Surgery needed because of the injury. The injury must not be one which is excluded by the terms of this section. 67
Arizona Plan Guide Checklist For more information about Aetna s Small Business Solutions, please contact your local Sales Executive or the Small Group Service Center from 8 a.m. to 5 p.m. PT Toll-free: 1-877-249-2472 Fax: 1-888-258-4530 E-mail address: ASGBLAZ_NV_WA@Aetna.com Mailing Address: Aetna Small Group Underwriting P.O. Box 91507 Arlington, TX 76015-0007 Avoid potential delays in getting your client approved and enrolled. Make sure your new case submissions are complete. Employer Application Complete all pages of the application. Must be signed by the employer or a person authorized within the company. Number of eligible and enrolled employees. Contribution: Premium percentage paid by employer. Select the plans desired on page 1. COBRA: Completed form for any enrollees currently eligible or enrolled on COBRA. Dates: Applications must be signed and dated prior to and within ninety (90) days of the requested effective date. No altered applications (a new application will be required). Tax Documents Part-time, terminated, seasonal or temporary must be indicated on this wage and tax report, and signed and dated by the employer attesting to the written comments. Wage and Tax: All enrolling employees must be represented on the wage and tax form or included on a payroll report. Out-of-state employees: Require proof of employment if not identified on the UC018/UC020. This would be the quarterly wage and tax statement filed in that particular state where the employee is living and/or working. Owner, partner, or corporate officer: If not listed on the UC018/UC020, submit the Small Group Proof of Eligibility form signed by the employee along with the requested documents. Newly hired employees: If not identified on the Wage and Tax the employee s names should be written in on the Wage and Tax statement and signed and dated by employer attesting to the written comments. The underwriter may request payroll in questionable situations. Initial Premium A company check for 100% of the first month s medical, dental and life premiums payable to Aetna. Payment for the first month s premium at new business can be processed via an electronic funds transfer. Prior Carrier Bill If replacing medical and/or dental coverage provide a current carrier bill that includes employee roster and premium summary page. Employee Applications Any alterations must be initialed and dated by the employee. Waivers: For employees who are not enrolling. Enrollment Application Signature: Be sure they are signed and dated within ninety (90) days of the requested effective date. 68
Broker and General Agent Review Complete, sign, and date the Agent/Broker Certification section of the Employer Application. Review all items on this page for completion prior to submissions. Verify underwriting guidelines were reviewed and understood. Submit a copy of the Aetna quote package. Complete and provide the Aetna Agent Agreement, if applicable. Effective dates may be the 1 st or the 15 th of the month. In order for Aetna to honor the requested effective date, all completed paperwork submissions must be received no later than the end of the business day following the requested effective date. 69
Contact information Aetna small group broker and general agents Broker Sales Support Unit 1-877-249-2472 phone 1-888-258-4530 fax Choose the following numbers, when prompted, to access the information you need. Prompt 1 If you know your party s extension Prompt 2 Claims Prompt 3 Commissions Prompt 4 Licensing and appointment Prompt 5 Billing, enrollment and eligibility Prompt 6 Broker liaison E-mail Address ASGBLAZ_NV_WA@aetna.com Regular Mail P.O. Box 24004 Fresno, CA 93779-4004 Plan Sponsor Services 1-877-249-7235 phone Choose the following numbers, when prompted, to access the information you need. Prompt 1 Renewals Prompt 2 Claims Prompt 3 Billing and enrollment Billing For Lockbox information, see customer bill or please contact the Plan Sponsor Services toll-free number for more information. Enrollment Aetna P.O. Box 24005 Fresno, CA 93779-4005 enrollmentsgwest@aetna.com Overnight Mail 1385 East Shaw Avenue Fresno, CA 93710 New Business Quoting 1-866-572-1273 fax Medical Prescreens: SGQuoteAZPrescreens@aetna.com Standard Quote: SGQuoteAZStandard@aetna.com 51-100 Contact your Aetna representative. New Business Case Submission Mailing address Aetna Small Group Underwriting 4645 East Cotton Center Blvd. Building 1 Phoenix, AZ 85040 Aetna Navigator and Producer World 1-800-225-3375 Monday Friday 7 a.m. 9 p.m. ET Choose the following numbers, when prompted, to access the information you need. Prompt 1 (Aetna Member) Prompt 4 (Producer World) 70
Member services Medical For benefits questions or claims inquiries for Aetna HMO Plan, Aetna HNO 1-888-702-3862 Claims Address Aetna P.O. Box 14079 Lexington, KY 40512 For benefits questions or claims inquiries for Aetna PPO Plan, Aetna Choice Plan (MC), Savings Plus, Aetna Indemnity plan: 1-888-802-3862 Claims Address Aetna P.O. Box 981204 El Paso, TX 79998-1204 Dental 1-877-238-6200 Prompt 1 (Dental plan member) Prompt 2 (Dental care provider) Claims Address Aetna P.O. Box 14094 Lexington, KY 40512-4094 Life Claims Address Aetna Life Insurance P.O. Box 14548 Lexington, KY 40512-4548 1-800-523-5065 Mail-Order Drugs 1-888-318-3937 Ordering Address Aetna Rx Home Delivery P.O. Box 417019 Kansas City, MO 64179-9892 To track and order Rx refills: www.aetnanavigator.com Other Programs Aetna Vision SM Discount Program 1-800-793-8616 Call for closest eye care provider. Informed Health Line 1-800-556-1555 24-Hour Nurse Help Line. Aetna Behavioral Health 1-800-424-5702 For the Aetna Natural Products and Services SM program and Aetna Fitness SM program, visit the DocFind directory or your Aetna Navigator website for a list of providers and information. Visit our secure member website online Your secure Aetna Navigator member website is available 24 hours a day, 7 days a week. Use it to perform common transactions involving your Aetna medical, dental, prescription drug or flexible spending account (FSA) plans. You can send a secure e-mail to Aetna Member Services, access claims, see who s covered and view general health information and decision-support tools. Log in to the Aetna Navigator website at www.aetna.com. Pharmacy 1-800-AETNA RX or 1-800-238-6279 Prompt 2 (Member or calling on behalf of member) Claims Address Aetna Pharmacy Management P.O. Box 14024 Lexington, KY 40512-4024 71
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health/Dental benefits, health/dental insurance, life and disability insurance plans/policies contain exclusions and limitations. If you are in a plan, health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Investment services are independently offered through HealthEquity, Inc. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Aetna may receive a percentage of the fee you pay to the discount providers. The Aetna Personal Health Record should not be used as the sole source of information about the member s medical history. Plan for Your Health is a public education program from Aetna and The Financial Planning Association. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health, dental and disability services are covered. See plan documents for a complete description of benefits,exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. www.aetna.com 2012 Aetna Inc. 14.02.970.1-AZ L (2/13)