Aetna Advantage Plans for Individuals, Families and the Self-Employed

AETNA ADVANTAGE PLANS FOR INDIVIDUALS, FAMILIES AND THE SELF-EMPLOYED

NEW PROVISIONS EFFECTIVE SEPTEMBER 23, 2010 This information is an addendum to the printed materials you received.

The federal health care The following health care Please note that some previously reform legislation, known reform changes are effective printed materials do not reﬂ ect these as the Patient Protection on September 23, 2010: changes. However, the new provisions are in effect and Affordable Care Act, • Allow dependent coverage up for plans with an effective was signed into law to age 26 date on or after September 23, 2010, and your Aetna Advantage Plan does on March 23, 2010 by • Remove lifetime beneﬁ t limits – comply with the new federal health based on dollar amounts President Obama. care reform legislation. • Take away cost-sharing obligations for preventive services (In network) If you have any questions, please talk to • Eliminate pre-existing condition your broker or call 1-800-MY-HEALTH. exclusions for dependent children (under 19 years of age)

Please note that in addition to health care reform changes, coverage for children only may no longer be available in your state. Also, all plans described in the printed material you received may not currently be available in your state. Aetna Advantage Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company (Aetna) directly and/or through an out-of-state blanket trust or Aetna Health Inc. In some states, individuals may qualify as a business group of one and may be eligible for guaranteed issue, small group health plans. These plans are medically underwritten and you may be declined coverage in accordance with your health condition. ©2010 Aetna Inc. 13.03.536.1 (7/10) Take charge of your health. We’re here to help. Aetna Advantage plans for individuals, families and the self-employed in Missouri

The information you need to choose quality and affordable health insurance coverage.

AA.02.305.1-MO (1/10) B Choose Aetna, choose affordable coverage

Understanding Your Choices 1) See what plans are available

Aetna Advantage Plan Details 2) Choose the insurance coverages that are right for you

More Value with Aetna Special Programs 3) Substantial savings on programs to help you stay healthy

What You Need to Know 4) Learn more about what’s included

Aetna Advantage Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company (Aetna) directly and/or through an out-of-state blanket trust. In some states, individuals may qualify as a business group of one and may be eligible for guaranteed issue, small group health plans. These plans are medically underwritten and you may be declined coverage in accordance with your health condition.

1-800-My Health | www.aetnaindividual.com Choose Aetna, choose affordable coverage

Here are our top reasons why the Aetna Advantage Enroll Online plans offer some of the best choices and value to or By Mail help meet your health coverage needs. Use this guide to narrow down your plan choices. Then, get a free Affordable quality & choices Family coverage quote and enroll for a policy either online or by mail. Choose from a wide range of health Apply for coverage for yourself, your insurance plans that offer excellent spouse, and children, or even just your Online: quality. Our plans are designed for children. Coverage can include prescription maximum value, with lower monthly drugs, doctor visits, hospitalization and 1. Visit www.aetnaindividual.com. premiums, plus benefits for preventive care. preventive care services. 2. Choose your state. You can choose how much to spend in 3. Choose the best plan for you. premiums versus out-of-pocket expenses. Tax advantages 4. Click “Get A Quote.” We also offer High Deductible plans that 5. Apply online and submit an Robust coverage, are compatible with tax-advantaged Health electronic form of payment. competitive costs Savings Accounts (HSAs). You can contribute (Or mail the enclosed enrollment We offer plans with valuable features money to your HSA tax-free. That money form with one form of payment which may include: earns interest tax-free. And qualified withdrawals for medical expenses are selected.) n An excellent combination of tax-free, too. quality coverage and competitively 6. Track the status of your priced premiums. enrollment form by clicking the n The freedom to see doctors whenever Help with health information site’s Apps tab. you need to, with no referrals needed. Need health information fast? We offer By Mail: n Covers preventive care, prescription secure Internet access to reliable health Complete and mail the enclosed drugs, doctor visits, hospitalization tools and resources. Learn more about and children’s immunizations. Aetna Navigator® and the Informed enrollment form, in the envelope n No deductible for well-women exams Health® Line in Section 3 - More Value provided, with one form of when you visit a network provider. with Aetna Special Programs. payment selected. n No claim forms to fill out when you use a network provider. Coverage when you travel n Aetna’s nationwide provider network offers you a vast selection of licensed Like to travel? You’re covered by a physicians and hospitals. nationwide network of doctors and hospitals that accept Aetna’s negotiated fees.

Have questions? Just e-mail [email protected] or call 1-800-MY-HEALTH (1-800-694-3258).

Want a quote now? Visit www.aetnaindividual.com or call 1-800-MY-HEALTH (1-800-694-3258). 1 Understanding your 1) Aetna Advantage plan choices

Our plans are designed to offer About HSAs Is your doctor in the you quality coverage at an excellent Many of our high-deductible plans are Health Aetna network? value. Coverage can include Savings Account (HSA) Compatible, offering Which local physicians, hospitals, pharmacies prescription drugs, doctor visits, you lower premiums and tax advantaged and eyewear providers participate in the hospitalization and preventive savings. An HSA is a personal account that nationwide Aetna Advantage Plan network? care services. lets you pay for qualified medical expenses Visit www.aetna.com/docfind/custom/ Generally speaking, the lower your with tax advantaged funds. You or an eligible advplans. Or call 1-800-694-3258 and ask for “premiums,” or monthly payments, the family member make contributions to your a directory of providers. higher your “deductible,” which is the HSA tax-free, and those dollars earn interest amount you pay out of pocket before tax-free. Then, when you make withdrawals Get more from your Aetna plan the plan begins paying for expenses. from your account to pay for qualified health care expenses, they’re tax-free, too. Cover just your children You’ll pay less by using “in-network” Aetna Advantage Plans are also available for doctors, hospitals, pharmacies and other It’s easy to establish a children only, which means you can enroll your health care providers who participate in Health Savings Account… child even if no other family member enrolls. Aetna’s nationwide network than by using Simply enroll in an Aetna HSA Compatible Coverage includes immunizations, well-child “out-of-network” doctors. High Deductible Health Plan and you will visits, emergency room and dental preventive Visit www.planforyourhealth.com for automatically have an HSA opened through services (if a dental plan is selected). an in-depth list of terms in this brochure Bank of America. You will also receive a debit Note: when an HSA Compatible plan is selected and what they mean. card and a welcome package with additional for child only enrollment, an HSA account is not information to get you started. available for the child. If you do not wish to set up an HSA, you can opt out by calling Bank of America – or the Add Dental PPO Max account will be automatically canceled after With the Aetna Advantage Dental PPO Max 90 days if the debit card is not activated or insurance plan, you can obtain services from if you do not enroll online. either a participating or non-participating dentist. Participating dentists have agreed Why choose an Aetna to provide services at a negotiated rate HealthFund HSA? for both covered services, as well as non- covered services such as cosmetic tooth n No set-up fees whitening and orthodontic care, so you n No monthly administration fee generally pay less out-of-pocket. You also n No withdrawal forms required have the flexibility to visit a dentist who does n Convenient access to HSA funds via debit not participate in Aetna’s network, though card or online you will not have access to negotiated fees. n Track HSA activity online Dental coverage is offered only if medical coverage is obtained.

2 1-800-My Health | www.aetnaindividual.com What Does That Mean?

Here are a few definitions of terms you’ll see throughout Understanding your this brochure. For a more in- depth list of terms, please visit Aetna Advantage plan choices www.planforyourhealth.com.*

Aetna’s Missouri Ratings Areas* Deductible – A fixed yearly dollar amount you pay before the benefits of Your rates will depend on the area in which your county is located. the plan policy start. For more information or a quote on what your rate would be, call 1-800-MY HEALTH. Coinsurance – The dollar amount that the plan and you pay for covered benefits Area 1 Counties after the deductible is paid. Adair Dekalb Lewis Ray Andrew Dent Linn Saint Clair Copayment (Copay) – A fixed dollar Atchison Gentry Macon Schuyler amount that you must contribute toward Benton Harrison Marion Scotland the cost of covered medical services Buchanan Holt Mercer Shannon under a health plan. For HSA compatible Cass Howell Nodaway Shelby plans, copayment will apply to your Clark Jackson Pike Sullivan out-of-pocket max. Clay Knox Platte Texas Clinton Laclede Putnam Vernon Exclusions and Limitations — Specific Daviess Lafayette Ralls Worth conditions or circumstances that are not Area 2 Counties covered under a plan. Audrain Cole McDonald Pettis Lifetime Maximum – The total dollar Barton Cooper Miller Phelps amount of benefits you may receive, or the Bates Dunklin Mississippi Pulaski Bollinger Gasconade Moniteau Randolph limited number of particular services you Boone Grundy Monroe Reynolds may receive, over the term of the policy. Butler Henry Montgomery Ripley Out-of-Pocket Maximum – The Caldwell Howard Morgan Saline Callaway Iron New Madrid Scott amounts such as coinsurance and Camden Jasper Newton Stoddard deductibles that an individual is required Cape Girardeau Johnson Oregon Wayne to contribute toward the cost of health Carroll Livingston Osage services covered by the benefits plan. Carter Madison Pemiscot Chariton Maries Perry Premium – The amount charged, often in installments, for an insurance policy. Area 3 Counties Barry Dallas Lawrence Taney Pre-existing Condition – A health Cedar Douglas Ozark Webster condition (other than a pregnancy) or Christian Greene Polk Wright medical problem including the use of Dade Hickory Stone prescription drugs that was diagnosed or treated before getting insurance from a Area 4 Counties new health plan. Crawford Lincoln Saint Louis Warren Franklin Saint Charles Saint Louis City Washington Jefferson Saint Francois Sainte Genevieve

* Plan For Your Health is a public education program from Aetna and the Financial Planning Association. * Networks may not be available in all ZIP codes and are subject to change. 3 2) Plan Details First Dollar PPO 30 First Dollar PPO 40 MEMBER BENEFITS In-Network Out-of-Network+ In-Network Out-of-Network+ Deductible First Dollar PPO Individual $0 $5,000 $0 $7,000 Family $0 $10,000 $0 $14,000 plan options Coinsurance 30% up to 50% after 40% up to 50% after (Member’s responsibility) out-of-pocket max. deductible up to out-of-pocket max. deductible up to out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Individual $7,500 $7,500 $12,500 $5,500 Family $15,000 $15,000 $25,000 $11,000 Out-of-Pocket Maximum Individual $7,500 $12,500 $12,500 $12,500 Family $15,000 $25,000 $25,000 $25,000 Includes deductible Includes deductible Robust coverage and lower Lifetime Maximum* per insured $5,000,000 $5,000,000 out-of-pocket expenses with Non-Specialist Office Visit $30 copay 50% $40 copay 50% Unlimited visits after deductible after deductible no deductibles when you General Physician, Family choose a network provider Practitioner, Pediatrician or Internist Specialist Visit $40 copay 50% $50 copay 50% Unlimited visits after deductible after deductible Featuring: Hospital Admission 30% 50% 40% 50% after deductible after deductible n Lower copay for in-network Outpatient Surgery 30% 50% 40% 50% provider visits after deductible after deductible n No deductible for generic Urgent Care Facility $50 copay 50% $50 copay 50% after deductible after deductible prescription drugs Emergency Room $100 copay** (waived if admitted) $100 copay** (waived if admitted) 30% coinsurance 40% coinsurance Annual Routine Gyn Exam $0 copay 50% $0 copay 50% No waiting period, no calendar year after deductible after deductible max. Annual Pap/Mammogram Maternity Not covered Not covered Plus: Except for pregnancy complications Except for pregnancy complications n Coverage for office visits to your Preventive Health — $30 copay 50% $40 copay 50% Routine Physical after deductible after deductible primary care physician and specialists Aetna will pay up to $200 per exam* Includes lab work and X-rays n No claim forms to fill out when you No waiting period Includes lab work and X-rays visit a network provider Lab/X-Ray 30% 50% 40% 50% n No referrals required to see a specialist after deductible after deductible n No waiting period for routine Skilled Nursing — 30% 50% 40% 50% in lieu of hospital after deductible after deductible physical exams 30 days per calendar year* n 100% annual routine GYN exam Physical/Occupational Therapy 30% 50% 40% 50% coverage — no waiting period, and Chiropractic Care after deductible after deductible 24 visits per calendar year* no dollar maximum and no copay Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit* or deductible when you visit a Home Health Care — 30% 50% 40% 50% network provider in lieu of hospital after deductible after deductible 30 visits per calendar year* n Coverage for prescription drugs n Durable Medical Equipment 30% 50% 40% 50% Coverage for routine physicals including Aetna will pay up to $2,000 per after deductible after deductible lab work and X-rays calendar year* n 100% coverage for in-network PHARMACY childhood immunizations Pharmacy Deductible $500 $500 Not Applicable Not Applicable per individual Generic $15 copay $15 copay $20 copay $20 copay Oral Contraceptives Included deductible waived plus 50% plus 50% deductible waived * Maximum applies to combined in and out-of- network benefits. Preferred Brand $40 copay $40 copay Not covered Not covered ** Copay is billed separately and not due at time of Oral Contraceptives Included after deductible plus 50% Aetna Discount service. Copay does not count towards coinsurance after deductible Applies or out-of-pocket maximum. + Payment for out-of-network facility covered Non-Preferred Brand $60 copay $60 copay Not covered Not covered expenses is determined based on Aetna’s Market Oral Contraceptives Included after deductible plus 50% Aetna Discount Fee Schedule. Payment for out-of-network non- after deductible Applies facility covered expenses is determined based on the Calendar Year Maximum Unlimited Unlimited Unlimited Unlimited negotiated charge that would apply if such services per individual* were received from a Network Provider.

4 1-800-My Health | www.aetnaindividual.com PPO 1000 PPO 1500

MEMBER BENEFITS In-Network Out-of-Network+ In-Network Out-of-Network+

Deductible PPO Individual $1,000 $2,000 $1,500 $3,000 Family $2,000 $4,000 $3,000 $6,000 plan options Coinsurance 20% after 50% after 20% after 50% after (Member’s responsibility) deductible up to deductible up to deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Individual $2,000 $8,000 $1,500 $7,000 Family $4,000 $16,000 $3,000 $14,000 Out-of-Pocket Maximum Individual $3,000 $10,000 $3,000 $10,000 Family $6,000 $20,000 $6,000 $20,000 Includes deductible Includes deductible Robust coverage and lower Lifetime Maximum* per insured $5,000,000 $5,000,000 monthly payments balanced Non-Specialist Office Visit $20 copay 50% $25 copay 50% Unlimited visits deductible waived after deductible deductible waived after deductible with a deductible…where you General Physician, Family don’t want to pay a lot for Practitioner, Pediatrician or Internist Specialist Visit $30 copay 50% $35 copay 50% frequent doctor visits Unlimited visits deductible waived after deductible deductible waived after deductible Hospital Admission 20% 50% 20% 50% Featuring: after deductible after deductible after deductible after deductible Outpatient Surgery 20% 50% 20% 50% after deductible after deductible after deductible after deductible n Health insurance coverage with Urgent Care Facility $50 copay 50% $50 copay 50% lower monthly premiums and deductible waived after deductible deductible waived after deductible varying deductible levels Emergency Room $100 copay** (waived if admitted) $100 copay** (waived if admitted) 20% coinsurance after deductible 20% coinsurance after deductible Annual Routine Gyn Exam $0 copay 50% $0 copay 50% No waiting period, no calendar year deductible waived after deductible deductible waived after deductible max. Annual Pap/Mammogram Maternity Not covered Not covered Except for pregnancy complications Except for pregnancy complications Plus: Preventive Health — $20 copay 50% $25 copay 50% n Coverage for office visits to your Routine Physical deductible waived after deductible deductible waived after deductible primary care physician and specialists Aetna will pay up to $200 per exam* No waiting period Includes lab work and X-rays Includes lab work and X-rays n No claim forms to fill out when you Lab/X-Ray 20% 50% 20% 50% visit a network provider after deductible after deductible after deductible after deductible n No referrals required to see a specialist Skilled Nursing — 20% 50% 20% 50% n No waiting period for routine in lieu of hospital after deductible after deductible after deductible after deductible physical exams 30 days per calendar year* Physical/Occupational Therapy 20% 50% n 20% 50% 100% annual routine GYN exam and Chiropractic Care after deductible after deductible after deductible after deductible coverage — no waiting period, 24 visits per calendar year* Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit* no dollar maximum and no copay or deductible when you visit a Home Health Care — 20% 50% 20% 50% in lieu of hospital after deductible after deductible after deductible after deductible network provider 30 visits per calendar year* n Coverage for prescription drugs Durable Medical Equipment 20% 50% 20% 50% n Aetna will pay up to $2,000 per after deductible after deductible after deductible after deductible Coverage for routine physicals calendar year* including lab work and X-rays PHARMACY n 100% coverage for in-network Pharmacy Deductible $250 $250 $250 $250 childhood immunizations per individual Does not apply to generic Does not apply to generic Generic $15 copay $15 copay $15 copay $15 copay Oral Contraceptives Included deductible waived plus 50% deductible waived plus 50% deductible waived deductible waived * Maximum applies to combined in and out-of- network benefits. Preferred Brand $35 copay $35 copay $35 copay $35 copay ** Copay is billed separately and not due at time of Oral Contraceptives Included after deductible plus 50% after deductible plus 50% after service. Copay does not count towards coinsurance after deductible deductible or out-of-pocket maximum. Non-Preferred Brand $50 copay $50 copay $50 copay $50 copay + Payment for out-of-network facility covered Oral Contraceptives Included after deductible plus 50% after deductible plus 50% after expenses is determined based on Aetna’s Market after deductible deductible Fee Schedule. Payment for out-of-network non- facility covered expenses is determined based on the Calendar Year Maximum Unlimited Unlimited Unlimited Unlimited negotiated charge that would apply if such services per individual* were received from a Network Provider.

5 PPO 2500 PPO 5000 PPO MEMBER BENEFITS In-Network Out-of-Network+ In-Network Out-of-Network+ Deductible Individual $2,500 $5,000 $5,000 $10,000 plan options Family $5,000 $10,000 $10,000 $20,000

Coinsurance 20% after 50% after 20% after 50% after (Member’s responsibility) deductible up to deductible up to deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Individual $2,500 $5,000 $5,000 $2,500 Family $5,000 $10,000 $10,000 $5,000 Out-of-Pocket Maximum Individual $5,000 $10,000 $10,000 $12,500 Family $10,000 $20,000 $20,000 $25,000 Includes deductible Includes deductible Robust coverage and lower Lifetime Maximum* per insured $5,000,000 $5,000,000 Non-Specialist Office Visit $30 copay 50% $40 copay 50% monthly payments balanced Unlimited visits deductible waived after deductible deductible waived after deductible with a deductible…where you General Physician, Family Practitioner, Pediatrician or Internist don’t want to pay a lot for Specialist Visit $40 copay 50% $50 copay 50% frequent doctor visits Unlimited visits deductible waived after deductible deductible waived after deductible Hospital Admission 20% 50% 20% 50% Featuring: after deductible after deductible after deductible after deductible Outpatient Surgery 20% 50% 20% 50% after deductible after deductible after deductible after deductible n Health insurance coverage with Urgent Care Facility $50 copay 50% $50 copay 50% lower monthly premiums and deductible waived after deductible deductible waived after deductible varying deductible levels Emergency Room $100 copay** (waived if admitted) $100 copay** (waived if admitted) 20% coinsurance after deductible 20% coinsurance after deductible Annual Routine Gyn Exam $0 copay 50% $0 copay 50% No waiting period, no calendar year deductible waived after deductible deductible waived after deductible max. Annual Pap/Mammogram Maternity Not covered Not covered Except for pregnancy complications Except for pregnancy complications Plus: Preventive Health — $30 copay 50% $40 copay 50% n Coverage for office visits to your Routine Physical deductible waived after deductible deductible waived after deductible Aetna will pay up to $200 per exam* primary care physician and specialists Includes lab work and X-rays Includes lab work and X-rays No waiting period n No claim forms to fill out when you visit a network provider Lab/X-Ray 20% 50% 20% 50% after deductible after deductible after deductible after deductible n No referrals required to see a specialist Skilled Nursing — 20% 50% 20% 50% n No waiting period for routine in lieu of hospital after deductible after deductible after deductible after deductible physical exams 30 days per calendar year* n 100% annual routine GYN exam Physical/Occupational Therapy 20% 50% 20% 50% coverage — no waiting period, and Chiropractic Care after deductible after deductible after deductible after deductible 24 visits per calendar year* no dollar maximum and no copay Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit* or deductible when you visit a Home Health Care — 20% 50% 20% 50% network provider in lieu of hospital after deductible after deductible after deductible after deductible 30 visits per calendar year* n Coverage for prescription drugs Durable Medical Equipment 20% 50% 20% 50% n Coverage for routine physicals Aetna will pay up to $2,000 per after deductible after deductible after deductible after deductible including lab work and X-rays calendar year* n 100% coverage for in-network PHARMACY childhood immunizations Pharmacy Deductible $500 $500 $500 $500 per individual Does not apply to generic Does not apply to generic Generic $15 copay $15 copay $15 copay $15 copay Oral Contraceptives Included deductible waived plus 50% deductible waived plus 50% * Maximum applies to combined in and out-of- deductible waived deductible waived network benefits. Preferred Brand $35 copay $35 copay $35 copay $35 copay ** Copay is billed separately and not due at time of Oral Contraceptives Included after deductible plus 50% after deductible plus 50% service. Copay does not count towards coinsurance after deductible after deductible or out-of-pocket maximum. + Payment for out-of-network facility covered Non-Preferred Brand $50 copay $50 copay plus $50 copay $50 copay expenses is determined based on Aetna’s Market Oral Contraceptives Included after deductible 50% after deductible plus 50% Fee Schedule. Payment for out-of-network non- after deductible after deductible facility covered expenses is determined based on the Calendar Year Maximum Unlimited Unlimited Unlimited Unlimited negotiated charge that would apply if such services per individual* were received from a Network Provider.

6 1-800-My Health | www.aetnaindividual.com PPO High Deductible 3000 PPO High Deductible 5000 (HSA Compatible) (HSA Compatible) PPO MEMBER BENEFITS In-Network Out-of-Network+ In-Network Out-of-Network+ Deductible Individual $3,000 $6,000 $5,000 $10,000 High Deductible Family $6,000 $12,000 $10,000 $20,000

plan options Coinsurance 0% after 50% after 0% after 50% after (Member’s responsibility) deductible up to deductible up to deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Individual $0 $6,500 $0 $2,500 Family $0 $13,000 $0 $5,000 Out-of-Pocket Maximum Individual $3,000 $12,500 $5,000 $12,500 Family $6,000 $25,000 $10,000 $25,000 Includes deductible Includes deductible Lower premium costs…and Lifetime Maximum* per insured $5,000,000 $5,000,000 an HSA-compatible plan that Non-Specialist Office Visit 0% 50% 0% 50% offers tax advantaged savings Unlimited visits after deductible after deductible after deductible after deductible General Physician, Family Featuring: Practitioner, Pediatrician or Internist Specialist Visit 0% 50% 0% 50% n 0% coinsurance in network after Unlimited visits after deductible after deductible after deductible after deductible your deductible is met Hospital Admission 0% 50% 0% 50% after deductible after deductible after deductible after deductible n Lower monthly premiums, higher annual deductibles (at least $3,000 Outpatient Surgery 0% 50% 0% 50% after deductible after deductible after deductible after deductible for individuals and $6,000 for families) Urgent Care Facility 0% 50% 0% 50% n Can be paired with a tax-advantaged after deductible after deductible after deductible after deductible Health Savings Account (HSA) Emergency Room $0 copay after deductible $0 copay after deductible Annual Routine Gyn Exam $0 copay 50% $0 copay 50% No waiting period, no calendar year deductible waived after deductible deductible waived after deductible max. Annual Pap/Mammogram Maternity Not covered Not covered Plus: Except for pregnancy complications Except for pregnancy complications n Coverage for office visits to your Preventive Health — $20 copay 50% $25 copay 50% primary care physician and specialists Routine Physical deductible waived after deductible deductible waived after deductible Aetna will pay up to $200 per exam* n No claim forms to fill out when you No waiting period visit a network provider Includes lab work and X-rays Includes lab work and X-rays Lab/X-Ray 0% 50% 0% 50% n No referrals required to see a specialist after deductible after deductible after deductible after deductible n No waiting period for routine physical exams Skilled Nursing — 0% 50% 0% 50% n in lieu of hospital after deductible after deductible after deductible after deductible 100% annual routine GYN exam 30 days per calendar year* coverage — no waiting period, Physical/Occupational Therapy 0% 50% 0% 50% no dollar maximum and no copay and Chiropractic Care after deductible after deductible after deductible after deductible or deductible when you visit a 24 visits per calendar year* network provider Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit* n Coverage for prescription drugs Home Health Care — 0% 50% 0% 50% in lieu of hospital after deductible after deductible after deductible after deductible n Coverage for routine physicals 30 visits per calendar year* including lab work and X-rays Durable Medical Equipment 0% 50% 0% 50% n 100% coverage for in-network Aetna will pay up to $2,000 per after deductible after deductible after deductible after deductible childhood immunizations calendar year* PHARMACY Pharmacy Deductible Integrated Medical/ Integrated Medical/ Integrated Medical/ Integrated Medical/ per individual Rx Deductible Rx Deductible Rx Deductible Rx Deductible

* Maximum applies to combined in and out-of- Generic 0% after Medical/ 50% after Medical/ 0% after Medical/ 50% after Medical/ network benefits. Oral Contraceptives Included Rx deductible Rx deductible Rx deductible Rx deductible ** Copay is billed separately and not due at time of service. Copay does not count towards coinsurance Preferred Brand 0% after Medical/ 50% after Medical/ 0% after Medical/ 50% after Medical/ or out-of-pocket maximum. Oral Contraceptives Included Rx deductible Rx deductible Rx deductible Rx deductible + Payment for out-of-network facility covered expenses is determined based on Aetna’s Market Non-Preferred Brand 0% after Medical/ 50% after Medical/ 0% after Medical/ 50% after Medical/ Fee Schedule. Payment for out-of-network non- Oral Contraceptives Included Rx deductible Rx deductible Rx deductible Rx deductible facility covered expenses is determined based on the Calendar Year Maximum Unlimited Unlimited Unlimited Unlimited negotiated charge that would apply if such services per individual* were received from a Network Provider.

7 PPO Value 2500 PPO Value 5000 PPO Value MEMBER BENEFITS In-Network Out-of-Network+ In-Network Out-of-Network+ Deductible Individual $2,500 $5,000 $5,000 $10,000 plan options Family $5,000 $10,000 $10,000 $20,000 Coinsurance 30% after 50% after 30% after 50% after (Member’s responsibility) deductible up to deductible up to deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum Individual $2,500 $5,000 $5,000 $2,500 Family $5,000 $10,000 $10,000 $5,000 Out-of-Pocket Maximum Individual $5,000 $10,000 $10,000 $12,500 Family $10,000 $20,000 $20,000 $25,000 Includes deductible Includes deductible Lifetime Maximum* per insured $1,000,000 $1,000,000 Affordability — a balance Non-Specialist Office Visit Visits 1-2 $30 copay, 50% Visits 1-2 $30 copay, 50% Unlimited Visits deductible waived; after deductible deductible waived; after deductible of lower monthly premiums General Physician, Family Visit 3+ 30% after Visit 3+ 30% after Practitioner, Pediatrician or Internist deductible. Spec. deductible. Spec. and quality coverage… and non-spec share and non-spec share where you want to cap the visit max visit max amount you’ll spend on total Specialist Visit Visits 1-2 $30 copay, 50% Visits 1-2 $30 copay, 50% Unlimited Visits deductible waived; after deductible deductible waived; after deductible medical expenses each year Visit 3+ 30% after Visit 3+ 30% after deductible. Spec. deductible. Spec. and non-spec share and non-spec share Featuring: visit max visit max n Lower monthly premiums Hospital Admission 30% 50% 30% 50% (that’s the “Value” part) after deductible after deductible after deductible after deductible n No deductible for generic Outpatient Surgery 30% 50% 30% 50% prescription drugs after deductible after deductible after deductible after deductible Urgent Care Facility $50 copay 50% $50 copay 50% deductible waived after deductible deductible waived after deductible Emergency Room $100 copay** (waived if admitted) $100 copay** (waived if admitted) 30% coinsurance after deductible 30% coinsurance after deductible Annual Routine Gyn Exam $0 copay 50% $0 copay 50% Plus: No waiting period, no calendar year deductible waived after deductible deductible waived after deductible n Coverage for office visits to your max. Annual Pap/Mammogram primary care physician and specialists Maternity Not covered Not covered Except for pregnancy complications Except for pregnancy complications n No claim forms to fill out when you Preventive Health — $50 copay 50% $50 copay 50% visit a network provider Routine Physical deductible waived after deductible deductible waived after deductible Aetna will pay up to $200 per exam* n No referrals required to see a specialist Includes lab work and X-rays Includes lab work and X-rays No waiting period n No waiting period for routine Lab/X-Ray 30% 50% 30% 50% physical exams after deductible after deductible after deductible after deductible n 100% annual routine GYN exam Skilled Nursing — 30% 50% 30% 50% coverage — no waiting period, in lieu of hospital after deductible after deductible after deductible after deductible no dollar maximum and no copay Physical/Occupational Therapy 30% 50% 30% 50% or deductible when you visit a and Chiropractic Care after deductible after deductible after deductible after deductible network provider Aetna will pay up to $25 per visit max.* Aetna will pay up to $25 per visit max.* Home Health Care — 30% 50% 30% 50% n Coverage for prescription drugs in lieu of hospital after deductible after deductible after deductible after deductible n Coverage for routine physicals 30 visits per calendar year* including lab work and X-rays Durable Medical Equipment 30% 50% 30% 50% after deductible after deductible after deductible after deductible n 100% coverage for in-network PHARMACY childhood immunizations Pharmacy Deductible $500 $500 $500 $500 per individual Does not apply to generic Does not apply to generic Generic $20 copay $20 copay $20 copay $20 copay Oral Contraceptives Included deductible waived plus 50% deductible waived plus 50% * Maximum applies to combined in and deductible waived deductible waived out-of-network benefits. Preferred Brand $40 copay $40 copay $40 copay $40 copay ** Copay is billed separately and not due at time Oral Contraceptives Included after deductible plus 50% after deductible plus 50% of service. Copay does not count towards after deductible after deductible coinsurance or out-of-pocket maximum. Non-Preferred Brand Not covered Not covered Not covered Not covered + Payment for out-of-network facility covered Oral Contraceptives Included Aetna Discount Aetna Discount expenses is determined based on Aetna’s Market Applies Applies Fee Schedule. Payment for out-of-network non- facility covered expenses is determined based on Calendar Year Maximum $5,000 $5,000 $5,000 $5,000 the negotiated charge that would apply if such per individual* services were received from a Network Provider.

8 1-800-My Health | www.aetnaindividual.com Preventive and Preventive and Hospital Care 3000 PPO Value 2500 PPO Value 5000 Hospital Care 1250 (HSA Compatible) MEMBER BENEFITS In-Network Out-of-Network+ In-Network Out-of-Network+ Preventive and MEMBER BENEFITS In-Network Out-of-Network+ In-Network Out-of-Network+ Deductible Deductible Individual $2,500 $5,000 $5,000 $10,000 Individual $1,250 $2,500 $3,000 $6,000 Family $5,000 $10,000 $10,000 $20,000 Hospital Care Family $2,500 $5,000 $6,000 $12,000 Coinsurance 30% after 50% after 30% after 50% after Coinsurance 20% after 50% after 20% after 50% after (Member’s responsibility) deductible up to deductible up to deductible up to deductible up to plan options (Member’s responsibility) deductible up to deductible up to deductible up to deductible up to out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. out-of-pocket max. $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied Coinsurance Maximum $0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied $5,000 $2,500 Individual $2,500 $5,000 Coinsurance Maximum $10,000 $5,000 Family $5,000 $10,000 Individual $3,000 $7,500 $2,000 $4,000 Out-of-Pocket Maximum Family $6,000 $15,000 $4,000 $8,000 Individual $5,000 $10,000 $10,000 $12,500 Family $10,000 $20,000 $20,000 $25,000 Out-of-Pocket Maximum Individual $5,000 $10,000 Includes deductible Includes deductible $4,250 $10,000 Family $8,500 $20,000 $10,000 $20,000 Lifetime Maximum* per insured $1,000,000 $1,000,000 Non-Specialist Office Visit Visits 1-2 $30 copay, 50% Visits 1-2 $30 copay, 50% Includes deductible Includes deductible Unlimited Visits deductible waived; after deductible deductible waived; after deductible Affordability is one of your Lifetime Maximum* per insured $1,000,000 $1,000,000 General Physician, Family Visit 3+ 30% after Visit 3+ 30% after top priorities and you use only Practitioner, Pediatrician or Internist deductible. Spec. deductible. Spec. Non-Specialist Office Visit Not covered Not covered Not covered Not covered and non-spec share and non-spec share basic health care services… General Physician, Family visit max visit max and want to keep your Practitioner, Pediatrician or Internist Specialist Visit Visits 1-2 $30 copay, 50% Visits 1-2 $30 copay, 50% monthly premiums lower Specialist Visit Not covered Not covered Not covered Not covered Unlimited Visits deductible waived; after deductible deductible waived; after deductible Visit 3+ 30% after Visit 3+ 30% after deductible. Spec. deductible. Spec. Featuring: Hospital Admission 20% 50% 20% 50% and non-spec share and non-spec share after deductible after deductible after deductible after deductible visit max visit max n Health insurance coverage with lower monthly premiums and varying Outpatient Surgery 20% 50% 20% 50% Hospital Admission 30% 50% 30% 50% after deductible after deductible after deductible after deductible after deductible after deductible after deductible after deductible deductible levels. Urgent Care Facility Not covered Not covered Not covered Not covered Outpatient Surgery 30% 50% 30% 50% after deductible after deductible after deductible after deductible Emergency Room $100 copay** (waived if admitted) $100 copay** (waived if admitted) Urgent Care Facility $50 copay 50% $50 copay 50% 20% coinsurance after deductible 20% coinsurance after deductible deductible waived after deductible deductible waived after deductible Annual Routine Gyn Exam $0 copay 50% $0 copay 50% Emergency Room $100 copay** (waived if admitted) $100 copay** (waived if admitted) No waiting period, no calendar year deductible waived after deductible deductible waived after deductible 30% coinsurance after deductible 30% coinsurance after deductible max. Annual Pap/Mammogram Annual Routine Gyn Exam $0 copay 50% $0 copay 50% Maternity Not covered Not covered No waiting period, no calendar year deductible waived after deductible deductible waived after deductible Plus: Except for pregnancy complications Except for pregnancy complications max. Annual Pap/Mammogram n No claim forms to fill out when you Maternity Not covered Not covered visit a network provider Preventive Health — $25 copay 50% $35 copay 50% Except for pregnancy complications Except for pregnancy complications Routine Physical deductible waived after deductible deductible waived after deductible n Preventive Health — $50 copay 50% $50 copay 50% No waiting period for routine Aetna will pay up to $200 per exam* Routine Physical deductible waived after deductible deductible waived after deductible physical exams No waiting period Includes lab work and X-rays Includes lab work and X-rays Aetna will pay up to $200 per exam* Includes lab work and X-rays Includes lab work and X-rays n 100% annual routine GYN exam No waiting period Lab/X-Ray Not covered Not covered Not covered Not covered coverage — no waiting period, Lab/X-Ray 30% 50% 30% 50% after deductible after deductible after deductible after deductible no dollar maximum and no copay Skilled Nursing — 20% 50% 20% 50% in lieu of hospital after deductible after deductible after deductible after deductible Skilled Nursing — 30% 50% 30% 50% or deductible when you visit a in lieu of hospital after deductible after deductible after deductible after deductible network provider Physical/Occupational Therapy Not covered Not covered Not covered Not covered Physical/Occupational Therapy 30% 50% 30% 50% n Coverage for routine physicals including and Chiropractic Care and Chiropractic Care after deductible after deductible after deductible after deductible lab work and X-rays Home Health Care — 20% 50% 20% 50% Aetna will pay up to $25 per visit max.* Aetna will pay up to $25 per visit max.* n 100% coverage for in-network in lieu of hospital after deductible after deductible after deductible after deductible Home Health Care — 30% 50% 30% 50% 30 visits per calendar year* in lieu of hospital after deductible after deductible after deductible after deductible childhood immunizations 30 visits per calendar year* Durable Medical Equipment Not covered Not covered Not covered Not covered Durable Medical Equipment 30% 50% 30% 50% PHARMACY after deductible after deductible after deductible after deductible PHARMACY Pharmacy Deductible Not Applicable Not Applicable Not Applicable Not Applicable per individual Pharmacy Deductible $500 $500 $500 $500 per individual Does not apply to generic Does not apply to generic Generic $15 copay $15 copay plus Not covered Not covered Oral Contraceptives Included 50% Aetna Discount Generic $20 copay $20 copay $20 copay $20 copay Applies Oral Contraceptives Included deductible waived plus 50% deductible waived plus 50% deductible waived deductible waived * Maximum applies to combined in and Preferred Brand Not covered Not covered Not covered Not covered Preferred Brand $40 copay $40 copay $40 copay $40 copay out-of-network benefits. Oral Contraceptives Included Aetna Discount Aetna Discount Oral Contraceptives Included after deductible plus 50% after deductible plus 50% ** Copay is billed separately and not due at time Applies Applies after deductible after deductible of service. Copay does not count towards coinsurance or out-of-pocket maximum. Non-Preferred Brand Not covered Not covered Not covered Not covered Non-Preferred Brand Not covered Not covered Not covered Not covered + Payment for out-of-network facility covered Oral Contraceptives Included Aetna Discount Aetna Discount Oral Contraceptives Included Aetna Discount Aetna Discount expenses is determined based on Aetna’s Market Applies Applies Applies Applies Fee Schedule. Payment for out-of-network non- Calendar Year Maximum $5,000 $5,000 $5,000 $5,000 facility covered expenses is determined based on Calendar Year Maximum Unlimited Unlimited Not Applicable Not Applicable per individual* the negotiated charge that would apply if such per individual* services were received from a Network Provider.

9 Aetna Advantage Plan options Individual Dental Ppo Max plan

MEMBER BENEFITS Preferred NonPreferred Annual Deductible per Member $25; $25; (Does not apply to Diagnostic and Preventive Services) $75 family maximum $75 family maximum Annual Maximum Benefit Unlimited Unlimited DIAGNOSTIC SERVICES Oral exams Periodic oral exam 100% deductible waived 100% deductible waived Comprehensive oral exam 100% deductible waived 100% deductible waived Problem-focused oral exam 100% deductible waived 100% deductible waived X-rays Bitewing — single film 100% deductible waived 100% deductible waived Complete series 100% deductible waived 100% deductible waived PREVENTIVE SERVICES Adult cleaning 100% deductible waived 100% deductible waived Child cleaning 100% deductible waived 100% deductible waived Sealants — per tooth Discount Not covered Fluoride application — with cleaning 100% deductible waived 100% deductible waived Space maintainers Discount Not covered BASIC SERVICES Amalgam fillings — 100% after deductible 100% after deductible 2 surfaces Resin fillings — 2 surfaces Discount Not covered Oral Surgery Extraction — exposed root or erupted tooth Discount Not covered Extraction of impacted tooth — soft tissue Discount Not covered MAJOR SERVICES Complete upper denture Discount Not covered Partial upper denture Discount Not covered (resin based) Crown — Porcelain with noble metal Discount Not covered Pontic — Porcelain with noble metal Discount Not covered Inlay — Metallic (3 or more surfaces) Discount Not covered Oral Surgery Removal of impacted tooth — partially bony Discount Not covered Endodontic Services Bicuspid root canal therapy Discount Not covered Molar root canal therapy Discount Not covered Periodontic Services Scaling & root planing — per quadrant Discount Not covered Osseous surgery — per quadrant Discount Not covered ORTHODONTIC SERVICES Discount Not covered

Access to negotiated discounts: members are eligible to receive non-covered services, including cosmetic services such as tooth whitening, at the PPO negotiated rate when visiting a participating PPO dentist. 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. Above list of covered services is representative. A summary of exclusions is listed later in this brochure. For a full list of benefit coverage and exclusions refer to the plan documents. All products not available in all counties. This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract.

10 1-800-My Health | www.aetnaindividual.com More value with 3) Aetna special programs

Aetna Advantage Plans include special programs1 to complement our standard health insurance coverage. These programs include health information programs and tools, and offer you access to substantial savings on products to help you stay healthy. These programs are offered in addition to your Aetna Advantage Plan and are NOT insurance. For more information on any of these programs, please visit us online at www.aetna.com.

SM Aetna Vision Aetna Visionsm discount program offers special savings on eye exams, contact lenses, frames, lenses, Discount Program LASIK eye surgery, and eye care accessories.

Aetna Natural Products and Eligible Aetna members and their families can access complementary health care products and services at SM Services Discount Program reduced rates through the Aetna Natural Products and Services discount program. Members can save on acupuncture, chiropractic care, massage therapy and dietetic counseling as well as on over-the-counter vitamins, herbal and nutritional supplements and other health-related products.

SM Aetna Fitness Discount Eligible Aetna members and their families can access the GlobalFit™ national network of nearly 10,000 Program fitness clubs, in the United States and Canada, at preferred rates*. In addition, members can access other programs such as at-home weight loss programs, home fitness options and even one-on-one health coaching** services.

SM Aetna Weight Management The Weight ManagementSM discount program can help you achieve your weight loss goals by providing Discount Program you with a sensible weight loss plan and balanced nutrition guide to fit your lifestyle. This program provides Aetna members and their eligible family members access to discounts on Jenny Craig® weight loss programs and products.

SM Aetna Hearing Aetna’s HearingSM discount program helps Aetna members and their families save on hearing exams, Discount Program hearing services and hearing aids.

® Aetna Rx Home Delivery With this mail order prescription drug program, order prescription medications through our convenient and easy-to-use mail order pharmacy. To learn more or obtain order forms, visit www.AetnaRxHomeDelivery.com.

® Informed Health Line Our 24-hour toll-free number that puts you in touch with experienced registered nurses and an audio library for information on thousands of health topics.

® Aetna Navigator Register and log on to Aetna Navigator, Aetna’s secure member website, to check claims status, contact Aetna Member Services, estimate the costs of health care services, and more. Our new Aetna Navigator Health Information Guide provides a starting point to find answers about health care, types of treatment, cost of services and more to help members make more informed decisions. Plus, members have access to their own Personal Health Record***, a single, secure place where they can view their medical history and add other health information.

Discount programs provide access to discounted prices and are NOT insured benefits. 1 Availability varies by plan. Talk with your Aetna representative for details. * At some clubs, participation in this program may be restricted to new club members. ** Provided by WellCall, Inc. through GlobalFit. *** The Aetna Personal Health Record should not be used as the sole source of information about your health conditions or medical treatment.

11 Things you 4) need to know

Easy-Pay To qualify for an Aetna Medical underwriting Simple Automatic Payments via Advantage Plan, you must be: requirements Electronic Funds Transfer (EFT) n Under age 64 3/4 (If applying as a The Aetna Advantage Plans are not guaranteed issue plans and require medical Registration: Complete the payment couple, both you and your spouse section of the Aetna Advantage Plans must be under 64 3/4.) underwriting. Some individuals may qualify enrollment form. Select the EFT option n Dependents are covered up to age 24 as federally eligible under the Health to approve the automatic withdrawal of n Legal residents in a state with products Insurance Portability Accountability Act your initial premium and all subsequent offered by the Aetna Advantage Plans (HIPAA) through the Missouri Health premium payments. n Legal U.S. residents for at least six Insurance Pool (MHIP) program. Invoices: You will not receive a paper continuous months All applicants, enrolling spouses and invoice when you are enrolled in EFT. Your premium payments dependents are subject to medical Payments will appear on your bank underwriting to determine eligibility and Your rates are guaranteed not to increase statement as “Aetna Autodebit Coverage.” appropriate premium rate level. for 12 months from your effective date once Terminating: To terminate EFT, you will you’ve been accepted for coverage. After We offer various premium rate levels need to provide Aetna with 10 days that, your premiums may change. Final rates based on the medical underwriting of written notice prior to the date your next are subject to underwriting review. each applicant. EFT payment will be deducted. Without this written notice, your bank account may Your coverage be debited for the next month’s premium. 10-day right to review You will then need to contact Aetna to Your coverage remains in effect as long Do not cancel your current insurance until have funds placed back in the checking as you pay the required premium charges you are notified that you have been accepted account. on time, and as long as you maintain for coverage. We’ll review your enrollment eligibility in the plan. Coverage will be form to determine if you meet underwriting Refunds: To process an EFT refund terminated if you become ineligible due requirements. If you’re denied, you’ll be notified (placing money back in member’s checking to any of the following circumstances: by mail. If you’re approved, you’ll be sent an account), Aetna will require at least five n Aetna Advantage Plan contract and ID card. days after the withdrawal was made to Non-payment of premiums n ensure valid payment. Becoming a resident of a state or If, after reviewing the contract, you find that location in which Aetna Advantage you’re not satisfied for any reason, simply Rejected transactions: If the EFT Plans are not available payment rejects for any reason, Aetna will return the contract to us within 10 days. n Obtaining duplicate coverage automatically terminate the EFT and send We will refund any premium you’ve paid n For other reasons permissible by law you a letter saying you will receive paper (including any contract fees or other charges) invoices. Processing time to reinstate EFT Levels of coverage & enrollment less the cost of any services paid on behalf of will be 30–60 days. If an EFT payment is you or any covered dependent. rejected, you will need to pay that payment n You may be enrolled in your selected by paper check or credit card. plan at the premium charge. Duplicate coverage n You may be enrolled in your selected plan If you are currently covered by another carrier, Timing: Payments for Cycle 1 accounts at a higher premium, based on medical (1st of the month effective date) will be you must agree to discontinue the other underwriting. taken from your bank account between coverage before or on the effective date of n You may be declined coverage based on the 3rd and the 10th of the month the the Aetna Advantage Plan. Do not cancel your premium is due. Payments for Cycle 2 medical underwriting. current insurance until you are notified that accounts (15th of the month effective you have been accepted for coverage and date) will be taken from your bank are certain that you are keeping your Aetna account between the 18th and 23rd of Advantage Plan coverage. the month the premium is due. 12 1-800-My Health | www.aetnaindividual.com Limitations & exclusions n Experimental and investigational n Mental health not covered except for procedures, (except for coverage for severe biologically based mental or nervous Medical medically necessary routine patient care disorders These medical plans do not cover all health costs for Members participating in a cancer n Chemical dependency and substance care expenses and include exclusions and clinical trial) abuse not covered except for Drug and limitations. You should refer to your plan n Charges in connection with pregnancy care Alcohol dependencies associated with documents to determine which health care other than for pregnancy complications severe, biologically based mental or services are covered and to what extent. n Immunizations for travel or work nervous disorders n Implantable drugs and certain injectable Dental The following is a partial list of services drugs including injectable infertility drugs and supplies that are generally not covered. Listed below are some of the charges n Infertility services including artificial However, your plan documents may contain and services for which these dental plans insemination and advanced reproductive do not provide coverage. For a complete exceptions to this list based on state technologies such as IVF, ZIFT, GIFT, mandates or the plan design or rider(s). list of exclusions and limitations, refer to ICSI and other related services unless plan documents. Services and supplies that are generally not specifically listed as covered in your plan covered include, but are not limited to: documents n Dental Services or supplies that are n All medical and hospital services not n Non-medically necessary services or supplies primarily used to alter, improve or enhance specifically covered in, or which are limited n Orthotics appearance. Negotiated rates for cosmetic or excluded by your plan documents, n Over-the-counter medications and supplies procedures available when a participating including costs of services before coverage n Radial keratotomy or related procedures dentist is accessed. begins and after coverage terminates n Reversal of sterilization n Experimental services, supplies or n Ambulance coverage is limited to $1,000 n Services for the treatment of sexual procedures per trip dysfunction or inadequacies including n Treatment of any jaw joint disorder, such n Cosmetic surgery therapy, supplies or counseling as temporomandibular joint disorder n n Custodial care n Special or private duty nursing Replacement of lost or stolen appliances n Donor egg retrieval n Therapy or rehabilitation other than those and certain damaged appliances n n Weight control services including surgical listed as covered in the plan documents Services that Aetna defines as not procedures for the treatment of obesity, necessary for the diagnosis, care or medical treatment, and weight control/loss treatment of a condition involved programs n All other limitations and exclusions in your plan documents

Pre-existing Conditions During the first 12 months following your effective date of coverage, no coverage will be provided for the treatment of a pre-existing condition unless you have prior creditable coverage. A pre-existing condition is an illness, disease, physical condition, or injury for which medical advice, or treatment was recommended or received and/or the use of prescription drugs of any kind within six months preceding the effective date of coverage. Services or supplies for the treatment of a pre-existing condition are not covered for the first 12 months after the member’s effective date. If the member had continuous prior creditable coverage within the 63 days immediately preceding the signature on the application and meets certain other requirements, then the pre-existing condition exclusion of 12 months may not apply.

13 Want to save on dental expenses? Vital Savings by Aetna® is a discount program that provides you with dental savings. This is not insurance. Enrolling in the program will give you access to a network of providers who have agreed to accept discounted rates for services. To sign up today, visit www.vitalsavings.com or call 1-877-698-4825.

If you need this material translated into another language, please call Member Services at 1-866-565-1236. Si usted necesita este material en otro lenguaje, por favor llame a Servicios al Miembro al 1-866-565-1236. This material is for information only and is not an offer or invitation to contract. Plan features and availability may vary by location. Plans may be subject to medical underwriting or other restrictions. Rates and benefits may vary by location. Health/Dental insurance plans contain exclusions and limitations. Investment services are independently offered by the HSA Administrator. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See health insurance 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 makers 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. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc., that operates through mail order. 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 for Your Health is a public education program from Aetna and The Financial Planning Association. Information is believed to be accurate as of production date, however, it is subject to change. The Vital Savings by Aetna® program (the “Program”) is not insurance. The Program provides Members with access to discounted fees pursu- ant to schedules negotiated by Aetna Life Insurance Company for the Vital Savings by Aetna® discount program. The Program does not make payments directly to the providers participating in the Program. Each Member is obligated to pay for all services or products but will receive a discount from the providers who have contracted with the Discount Medical Plan Organization to participate in the Program. Aetna Life Insurance Company, 151 Farmington Avenue, Hartford, CT 06156, 1-877-698-4825, is the Discount Medical Plan Organization. For more information about Aetna plans, refer to www.aetna.com. 1-800-My Health | www.aetnaindividual.com

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