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Take charge of your health.

Choose Aetna,
Choose Affordable
Cover age
The information you need
to choose quality and
affordable health benefits
and insurance coverage.

63.43.300.1 (1/11)
LEARN ABOUT
YOUR PLAN CHOICES
AETNA ADVANTAGE PL ANS FOR INDIVIDUALS,
FAMILIES AND THE SELF-EMPLOYED
63.44.312.1 (1/11)

Aetna Advantage Plans for Individuals,


Families and the Self-Employed are under-
written 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. To the extent permitted by law, these
plans are medically underwritten and you may
be declined coverage in accordance with your
health condition.
HEALTH CARE REFORM —
WHAT YOU NEED TO KNOW

CHOICE OF PROVIDER
IF YOUR AETNA GROUP OR INDIVIDUAL HEALTH PLAN
generally requires or allows the designation of a primary care provider, you
have the right to designate any primary care provider who participates in our
network and who is available to accept you or your family members. If the plan
or health insurance coverage designates a primary care provider automatically,
then until you make this designation, your Aetna Group or Individual Health
Plan designates one for you. For information on how to select a primary care
provider, and for a list of the participating primary care providers, contact your
Employer. Or, if you are a current member in an Aetna Group or Individual
Health Plan, call the number on the back of your ID card.

If your Aetna Group or Individual Health Plan allows for the designation of
a primary care provider for a child, you may designate a pediatrician as the
primary care provider.

If your Aetna Group or Individual Health Plan provides coverage for obstetric or
gynecological care and requires the designation by a participant or beneficiary
of a primary care provider, then you do not need prior authorization from your
Aetna Group or Individual Health Plan or from any other person (including a
primary care provider) in order to obtain access to obstetrical or gynecological
care from a health care professional in our network who specializes in obstetrics
or gynecology.

The health care professional, however, may be required to comply with


certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals.
For a list of participating health care professionals who specialize in obstetrics
or gynecology, contact your Employer. Or, if you are a current member in an
Aetna Group or Individual Health Plan, contact the number on the back of your
ID card.
THANK YOU
FOR CONSIDERING THE AETNA ADVANTAGE PL ANS FOR INDIVIDUALS,
FAMILIES AND THE SELF-EMPLOYED. WE ARE PLEASED TO PRESENT THIS
INFORMATION KIT, WHICH YOU CAN USE TO FIND A HEALTH INSUR ANCE
PL AN THAT’S RIGHT FOR YOU.

APPLY/ENROLL INSTRUCTIONS Once you choose a plan, there are two options for you to apply/enroll.

1) If you are working 2) If you are applying/enrolling


with a broker: on your own:
63.44.313.1-CA (1/11)

MAIL PHONE
BROKER ONLINE
Complete and mail the Any questions? Just call
You have a partner in the You can visit us online at
process. Get personalized www.GetaQuickQuote.com. enclosed application/ 1-800-569-1156
assistance from your broker, This website offers easy ways enrollment form, in the and
who can answer your to find the plan that is best envelope provided, with one we’ll be happy to
questions, help you choose for you. You can browse our form of payment selected. answer your questions
the plan that’s right for you DocFind® online provider as well as help you
and guide you through the directory and apply online. complete the application.
application process.
TOP REASONS TO
CHOOSE AETNA
In 2010, for the third year in a row, Aetna was named the most admired
health care insurance company by Fortune magazine.*

RO BU ST CO VERAGE , COV E R AGE W HE N O NL I NE HE ALT H T O O L S


CO MPETITIVE COS T S Y OU T R AV E L AND R E S O UR C E S
We offer plans with valuable features, Like to travel? You have access to covered Need health information fast? We offer
which may include: services from a national network of doctors secure Internet access to reliable health
• An excellent combination of and hospitals that accept our negotiated fees. information tools and resources through
quality coverage and competitively our secure member website. Also, here
priced premiums FAMI LY C O V E R AGE are three examples of our online tools
• The freedom to see doctors whenever Apply for coverage for yourself, for you that will help make it easier for you to
you need to – without referrals and your spouse, or for your whole family. make informed decisions about your
health care:
• Coverage for preventive care,
prescription drugs, doctor visits,
TAX ADVANTAGE S • Member Payment Estimator
hospitalization and immunizations We also offer high-deductible plans Our group of Web-based decision-
• No copayments for well-women exams that are compatible with tax-advantaged support tools is designed to help you
when you visit a network provider health savings accounts (HSAs). You plan for your health care expenses
• No claim forms to fill out when you can contribute money to your HSA tax by giving you health care costs and
use a network provider free. That money earns interest tax free. other information you need to make
And qualified withdrawals for medical better decisions. For tools that provide
• National provider networks offer
expenses are tax free, too. both in- and out-of-network cost
you a vast selection of participating
information, you can see the potential
physicians and hospitals
cost savings when a participating
in-network provider (physician, dentist
and facility) is used.
• Aetna SmartSourceSM
Aetna SmartSource will change the
way you research conditions, symptoms
and more. Unlike most search engines
LET’S TALK and general health websites, Aetna
SmartSource delivers information that is
specific to you based on where you live,
HAVE QUESTIONS? WANT A QUOTE NOW? your selected Aetna insurance plan
and other information.
• Mobile Web
Call Visit Mobile access to the most popular
1-800-569-1156 GetaQuickQuote.com and useful features of Aetna.com
or or is simplified for on-the-go use. Our
health-related mobile applications can
Email Call
help you save money and easily access
dennisa@getaquickquote.com 1-800-569-1156
health information.

* Fortune magazine, March 22, 2010, March 16, 2009, and March 17, 2008
MORE REASONS TO CHOOSE
AN AETNA ADVANTAGE PLAN

A FFO RD A BLE QUALIT Y You’ll pay less by using “in-network” AB O UT HE ALT H SAV I N G S
A ND CH OICES doctors, hospitals, pharmacies and other AC C O UNT S (HS As )
Our plans are designed to offer you health care providers who participate Many of our high-deductible plans are
quality coverage at an excellent value. in the Aetna network than by using health savings account (HSA) compatible.
You can choose from a wide range of “out-of-network” providers. That means you pay lower premiums
health insurance plans that offer varying This allows you to be in control of how and get tax-advantaged savings. An
amounts of coverage depending on you much you spend by matching the type HSA is a personal account that lets you
or your family’s specific needs. of coverage you desire with the premium pay for qualified medical expenses with
that matches your budget. tax-advantaged funds. You or an eligible
Generally speaking, the lower your
family member make contributions to
“premiums,” or monthly payments, the
your HSA tax free, and those dollars earn
higher your “deductible,” which is the
interest tax free. Then, when you make
amount you pay out of pocket before the
withdrawals from your account to pay for
plan begins paying for covered expenses.
qualified health care expenses, they’re
tax free, too.
OUR PL ANS ARE DESIGNED TO OFFER YOU
QUALIT Y COVER AGE AT AN EXCELLENT VALUE

FAMILY COVER AGE


Apply for coverage for yourself, for you and your spouse,
or for your whole family.

I T ’ S EA SY TO number as required by law. Please be W HAT DO E S T H AT M E A N ?


E S TABLISH A N HSA assured that the bank must keep all Here are a few definitions of terms
With an Aetna HSA compatible personal data confidential, as set by law. you’ll see throughout this brochure.
high-deductible health plan, you Bank of America will send you an For a more in-depth list of terms, please
will automatically have an HSA enrollment kit and a debit card. If you visit www.planforyourhealth.com.*
opened through Bank of America. do not want this HSA, you can do one Coinsurance – The dollar amount
You will also receive a debit card and of two things. that the plan and you pay for covered
a welcome package with additional benefits after the deductible is paid.
• You can have the bank close the
information to get you started.
account. Call Bank of America at Copayment (Copay) – A fixed dollar
If you do not wish to set up an HSA, 1-877-319-8114 to do this. amount that you must contribute
you can opt out by calling Bank of toward the cost of covered medical
• Do not activate the debit card or your
America – or the account will be services under a health plan. For HSA
on-line account. The HSA will close
automatically canceled after 90 days if compatible plans, copayment will apply
after 90 days.
the debit card is not activated or if you to your out-of-pocket max.
do not enroll online. If you do want to keep the HSA, refer to
the enrollment kit to use the account. Deductible – A fixed yearly dollar
amount you pay before the benefits
W H Y CH OO SE AN AE T NA of the plan policy start.
H E ALTHFUND HS A? ADD DE NTAL P P O MAX
Exclusions and Limitations —
• No set-up fees With the Aetna Advantage Dental
Specific conditions or circumstances
PPO Max insurance plan, participating
• No monthly administration fee that are not covered under a plan.
dentists provide covered services at
• No withdrawal forms required negotiated rates and may also provide Out-of-Pocket Maximum – The
discounts on non-covered services amounts such as coinsurance and
• Convenient access to HSA funds via
such as cosmetic tooth whitening and deductibles that an individual is required
debit card or online payments
orthodontic care, so you generally pay to contribute toward the cost of
• Track HSA activity online less out of pocket. You also have the health services covered by the benefits
flexibility to visit a dentist who does plan before the plan pays 100% of
I M PO RTANT INFORM AT ION not participate in the Aetna network, additional out-of-pocket costs.
though you will not have access to Premium – The amount charged
When you sign up for a qualified high-
negotiated fees. for a health insurance policy or health
deductible health plan, we will set up a
Health Savings Account (HSA) for you Note: Dental coverage is available only benefits plan on a monthly basis.
with Bank of America. Bank of America if you purchase medical coverage. Pre-existing Condition – A health
is our HSA Administrator for this plan. Discounts for non-covered services may condition or medical problem that
not be available in all states. was diagnosed or treated (including
We will give the bank all the information
they need to set up the HSA for you. the use of prescription drugs) before
This will include your social security getting coverage under a new insurance
health plan.

* Plan For Your Health is a public education program from Aetna and the Financial Planning Association.
VALUE-ADDED PROGRAMS
AETNA ADVANTAGE PL ANS INCLUDE SPECIAL PROGR AMS1
TO COMPLEMENT OUR HEALTH COVER AGE

These programs include health information programs and tools, HEALTH


and offer you access to substantial savings on products to help you
stay healthy. These programs are offered in addition to your Aetna
MANAGEMENT
Advantage Plan and are NOT insurance. TOOLS
Following is a description of some of the discount programs included with
INFORMED HEALTH ® LINE
our plans. For more information on any of these programs, please visit us
Our 24-hour toll-free number that
online at www.aetna.com. puts you in touch with experienced
registered nurses and an audio library
for information on thousands of
health topics.
DISCOUNT PROGR AMS THE AETNA SECURE
Aetna Fitness SM
Discount Program MEMBER WEBSITE
Offers preferred rates on gym memberships. It also offers discounts on Register and log on to our secure
at-home weight loss programs, home fitness options, and one-on-one health member website to check claims
status, contact Aetna Member Services,
coaching services through GlobalFitTM.
estimate the costs of health care
Aetna Hearing SM Discount Program services, and more. The secure member
website provides a starting point to
Provides access to discounts on hearing devices and hearing exams from
find answers about health care, types
HearPO®. Average savings on hearing aids is 25 percent.
of treatment, cost of services and more
to help members make more informed
Aetna Natural Products and Services SM
decisions. Plus, members have access
Discount Program
to their own Personal Health Record*,
Offers reduced rates on services from participating providers for acupuncture, a single, secure place where they can
chiropractic care, massage therapy and dietetic counseling. In addition, view their medical history and add other
discounts are available on over-the-counter vitamins, herbal and nutritional health information.
supplements and natural products. All products and services are provided
through American Specialty Health Incorporated (ASH) and its subsidiaries.
RELAYHEALTH
Aetna Vision SM
Discount Program RelayHealth is a secure, Web-based
doctor-patient service that makes it easy
Offers discounts on vision exams, lenses and frames. A member must
for members to communicate with their
use a provider in the EyeMed Select Network. LASIK surgery discounts are doctor’s offices. Members can use either
also available. a free “convenience services” or use a
reimbursable Web visit.
Aetna Weight Management SM Discount Program
Offers savings on eDiets® online diet plans, Jenny Craig® weight loss programs
and products and Nutrisystem weight loss meal plans. Members can meet
their specific weight loss goals and save money with a variety of programs
and plans to choose from.

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 vendor.
1 Availability varies by plan. Talk with your Aetna representative for details.
* The Aetna Personal Health Record should not be used as the sole source of information about your health conditions or medical treatment.
HOW CAN I SAVE MONEY
ON MY HEALTH CARE
BENEFITS EXPENSES?
It’s a sign of the times — people are Healthy Savings from Aetna gives you
looking to trim household expenses eight ways to start saving now with your
wherever they can. Aetna is here to help. Aetna health benefit plan. Take advantage
We’ve prepared special tips to help you of easy-to-follow tips, tools and charts
save money on health care benefits — that show you how you may save.
without compromising your health. Check out all the ways you can save at
www.aetna.com/healthysavings.
AETNA NETWORK PROVIDERS
SAVE YOU MONEY
KEEP ACCESS TO QUALITY CARE AFFORDABLE WITH THE AETNA PROVIDER NETWORK

I S YO U R DOCTOR IN THE I MP O RTANT ADDI T I O NAL I NF O R MAT I O N


A ETNA N ETWORK ? The “recognized amount”:
Our provider network is quite extensive
When you receive services from a provider who is not in the Aetna network, the
throughout the country, including your
plan pays based on the “recognized” amount/charge, which is described in your
state. In fact, your doctor may already
benefit plan. In these examples, if you use a health care provider who is not in
be part of the Aetna Advantage Plan
the Aetna network, you may be responsible for the entire difference between
network. To check which local physicians,
what the provider bills and the recognized amount/charge. As the examples
hospitals, pharmacies and eyewear
show, that difference can be large.
providers participate in your area, please
visit www.AetnaIndividual.com and select
“Find a Doctor”, or call 1-800-694-3258 E X A M PLE 1
and ask for a directory of providers.
By using providers in the Aetna network, You have been getting care for an ongoing condition from a specialist who is
you can take advantage of the significant not in the Aetna network. You are thinking about switching to a specialist in
discounts we have negotiated to help lower the Aetna network. This example illustrates what you may save if you switch.
your out-of-pocket costs for medically
necessary care. This can help you get the
care you need at an affordable price. OFFICE VISIT In-Network Out-of-Network+

Doctor bill Amount billed $150 $150


Let’s look at some examples, so you
can see your network savings in action. Amount Aetna uses Aetna’s rate* in-network $90*
to calculate payment
63.44.314.1 (1/11)

Recognized amount** $90**


These examples are based on the following out-of-network
Aetna plan features and assume you’ve
What your plan Aetna’s negotiated $90 $90
already met your deductible (the fixed amount will pay rate/ recognized amount
that you must pay for covered medical services Percent your plan pays 80% 60%
before your plan will pay benefits): Amount of Aetna’s $72* $54**
negotiated rate/recognized amount
What your plan pays covered under plan
(plan coinsurance): What you owe Your coinsurance responsibility $18 $36
80% in network / 60% out of network Amount that can be $0 $60
balance billed to you
What you pay (coinsurance):
Y O U R T O TA L R E S P O N S I B I L I T Y $18*** $96***
20% in network / 40% out of network
E X A M PLE 2

You need outpatient surgery for a simple procedure and are deciding
if you will have it done by a physician in the Aetna network.
This example gives you an idea of how much you might owe
depending on your choice.

O UT PAT I E NT S UR GE RY In-Network Out-of-Network+

Surgery bill† Amount billed $2,000 $2,000

Amount Aetna uses to Aetna’s rate* in-network $600*


calculate payment
Recognized amount** $600**
out-of-network
What your plan Aetna’s negotiated $600 $600
will pay rate/recognized amount
Percent your plan pays 80% 60%
Amount of Aetna’s $480* $360**
negotiated rate/recognized amount
covered under plan
What you owe Your coinsurance responsibility $120 $240
Amount that can be $0 $1,400*
balance billed to you

Y O U R T O TA L R E S P O N S I B I L I T Y $120*** $ 1 ,6 4 0 * * *

E X A M PLE 3

You need to go to the hospital but it is not an emergency.


BY USING PROVIDERS
It turns out that you have to stay in the hospital for five days.
This example gives you an idea of how much you might owe to IN THE AETNA
the hospital depending on whether it is in the Aetna network.
NET WORK, YOU CAN
F I V E- D AY H OSPITAL S TAY In-Network Out-of-Network+ TAKE ADVANTAGE
Hospital bill Amount billed $25,000 $25,000
OF THE SIGNIFICANT
Amount Aetna uses to Aetna’s rate* in-network $8,750*
calculate payment
Recognized amount** $8,750** DISCOUNTS WE HAVE
out-of-network
What your plan Aetna’s negotiated $90 $90 NEGOTIATED TO
will pay rate/ recognized amount
Percent your plan pays 80% 60% HELP LOWER YOUR
Amount of Aetna’s $7,000* $5,250**
negotiated rate/recognized amount OUT- OF-POCKET
covered under plan
What you owe Your coinsurance responsibility $1,750 $3,500 COSTS FOR MEDICALLY
Amount that can be $0 $16,250*
balance billed to you NECESSARY CARE.
YOUR TOTA L RESPO NSI BI L I TY $1,750*** $19,750***

† You also may be responsible for a portion of fees charged by the facility in which the surgery takes place. The figures in the example do not include those facility fees.
* Doctors, hospitals and other health care providers in the Aetna network accept our payment rate and agree that you owe only your deductible and coinsurance.
** When you go out of network, the plan determines a recognized amount. You may be responsible for the difference between the billed amount and the recognized amount.
See your plan documents for details. Your plan may instead call the recognized amount the recognized charge.
*** Most plans cap out-of-pocket costs for covered services. The deductible and coinsurance you owe count toward that cap. But when you go outside the network,
the difference between the health care provider’s bill and the recognized amount does not count toward that cap.
SAVE EVEN MORE
MORE WAYS TO CONTROL HEALTH CARE COSTS

E NJ O Y THE VALUE OF If a generic prescription drug is right AE T NA R X HO ME


G EN ERIC PRESCRIP T ION for you, we offer many ways to help DE L I V E RY ®
D RUGS you access them: With this mail-order prescription
Generic prescription drugs can save • Tools to compare the costs of drug program, order generic and
you money. They go through rigorous brand-name and generic drugs brand prescription medications through
testing as required by the Food and Drug • Outreach efforts that show how our convenient and easy-to-use mail
Administration. So you can be sure you can save with generic drugs order pharmacy. To learn more or
they are as safe and effective as their • Prescriptions filled with a generic, to download order forms, visit
brand-name counterparts. when appropriate www.AetnaRxHomeDelivery.com.
• Plan options that may include special
terms about use of generics

LOOK HOW MUCH YOU CAN SAVE!


SAVE ON LAB WORK
With your Aetna medical plan, you can In-network In-network Out-of-network
lab hospital lab lab
save on testing and other lab services
Cost of lab test $30.00 $60.00 $300.00
when you use Quest Diagnostics.
Patient’s copay x20% x20% x40%
Here’s how it works:
Patient pays $6.00 $12.00 $120.00
• If your doctor is collecting your sample
in the office, ask him or her to send
your testing to Quest. BE A BET TER HEALTH CARE CONSUMER.
• If your doctor is sending you outside
the office to collect your sample, ask ASK YOUR DOCTOR TO ONLY USE
for a lab requisition form to Quest,
and visit your nearest Quest office. IN - NET WORK L ABS, AND PAY LESS.
YOU’RE MOBILE. SO ARE WE.
Aetna Mobile puts our most popular When you go to Aetna.com from your
online features at your fingertips. No mobile phone’s web browser, you can:
matter where you are, you still want easy • Find a doctor, dentist or facility
access to your health information to make • Buy health insurance
the best decisions you can. • Register for your secure member site
• Access your personal health record
Want to look up a claim while you’re
(PHR)
waiting in line? Find a doctor and make an
• View your member ID card
appointment while you’re out shopping?
• Contact us by phone or email
Research the price of your medication
during your train ride to work? Explore a smarter health plan.
Visit us at www.getaquickquote.com
.
AETNA’S AEXCEL ®
DESIGNATED SPECIALISTS
FIND OUT MORE ABOUT THE AETNA PERFORMANCE NET WORK

Certain areas in your state include EFFIC I E NC Y More information is available on our
the Aetna Performance Network, secure Aetna Navigator® member
We also review the costs of treating
which features Aexcel designated website, at www.aetna.com. Just
Aetna members in each of the 12
specialists who have demonstrated log on, go to the “Provider Details”
Aexcel areas of care. We try to
cost-effectiveness in the delivery of care page, and click on the “View Clinical
include all costs — not just visits to
and met certain clinical performance Quality and Efficiency” tab. It shows
the doctor’s office.
measures. The Aexcel designation applies if the doctor meets standards for
to select specialists in 12 specialty areas: We review inpatient, outpatient, Aexcel designation.
Cardiology, Cardiothoracic Surgery, diagnostic, lab and pharmacy claims.
Aexcel information we offer you is
Gastroenterology, General Surgery, Then we compare the total costs of
intended to be only a guide for when
Obstetrics and Gynecology, Orthopedics, care from each doctor to the costs of
you choose a specialist within the
Otolaryngology/ ENT, Neurology, other doctors in the same region.
Aexcel specialist categories. There
Neurosurgery, Plastic Surgery, Urology and The doctors who best meet these are many ways to evaluate doctor
Vascular Surgery. Aetna members in the qualifications are chosen to receive practices and you should consult with
designated counties, described on the the Aexcel designation. your existing doctor before making a
Rating Areas page of this brochure,
How can I find an Aexcel- decision. Please note that all ratings
must choose Aexcel designated
designated doctor? have a risk of error and, therefore,
specialists or they will incur out-
should not be the sole basis for
of-network charges for any other You can look in your printed Aetna selecting a doctor.
provider in these 12 specialty areas. directory to find doctors with this
You can find more information on
Our performance network gives designation. Aexcel-designated doctors
Aexcel designation in our Understanding
63.44.315.1 (1/11)

you access to some high-performing have an asterisk next to their name.


Aexcel brochure. For a complete
specialists. Specialty doctors Or you can check our DocFind® description of performance measures
and doctor groups with the online provider directory. Please visit and how we evaluate doctors (data
Aexcel designation: www.AetnaIndividual.com and sources, statistical significance and other
• Are part of the Aetna network of select “Find a Doctor”. Aexcel-designated technical information) refer to the Aexcel
health care providers doctors have a blue star next to Methodology guide. It’s all available
• Have met certain industry-accepted their name. online on www.aetna.com. Just do a
practices for clinical performance search for “performance networks.”
• Have met our efficiency standards
BETTER MANAGE YOUR HEALTH
AND HEALTH CARE.
Aetna Navigator® Secure You even get personalized information.
Member Website And extra help is just a click or phone
Aetna Navigator helps you do what you call away!
want to do — more easily.
Visit Aetna Navigator anytime, anywhere.
As a member, you can log in to Log in using any mobile phone with web
manage your: access – www.aetna.com.
• Health coverage We look forward to welcoming you
• Claims as a member!
• Care and treatment
• Health records Explore a smarter health plan.
• Health and wellness Visit us at www.getaquickquote.com
.
RATING AREAS*
C A LI FO R NIA
YOUR RATES W IL L D EPEN D ON TH E A R E A IN WH IC H Y OU R C OU N T Y IS LOC AT E D .
F OR M ORE IN FOR MATION OR A QU OT E ON WH AT Y OU R R AT E WOU LD B E ,
CALL YO U R BROK ER OR 1 -800-MY-HE ALT H.

AREA 1 AREA 2 AREA 3


Aexcel Specialist Network** Aexcel Specialist Network** Aexcel Specialist Network**

San Diego Orange Los Angeles


(926-928) (905-908, 917)

AREA 4 AREA 5 AREA 6


Aexcel Specialist Network** Aexcel Specialist Network** Aexcel Specialist Network**

Los Angeles Riverside Los Angeles Alameda San Francisco


(910-916, San Bernardino (900-904, Contra Costa San Mateo
918, 935) Ventura (913) all other not in Marin Santa Clara
Imperial Area 3 or 4) Monterey Santa Cruz
San Benito

AREA 7 AREA 8 AREA 9


Aexcel Specialist Network** Aexcel Specialist Network**

Alpine Mono Amador Sacramento Butte Nevada


Calaveras San Joaquin El Dorado Solano Colusa Plumas
Fresno San Luis Obispo Napa Sonoma Del Norte Shasta
Inyo Santa Barbara Placer Yolo Glenn Sierra
Kern Stanislaus Humboldt Siskiyou
Kings Tulare Lake Sutter
Madera Tuolumne Lassen Tehama
Mariposa Ventura Mendocino Trinity
Merced (excluding 913) Modoc Yuba

AEXCEL ® -DESIGNATED SPECIALISTS**


The Aetna Performance Network features Aexcel-designated specialists who have
63.02.300.1-CA (1/11)

demonstrated cost-effectiveness in the delivery of care and met certain clinical


performance measures. The Aexcel designation applies to select specialists in 12
specialty areas: Cardiology, Cardiothoracic Surgery, Gastroenterology, General
Surgery, Obstetrics and Gynecology, Orthopedics, Otolaryngology/ENT, Neurology,
Neurosurgery, Plastic Surgery, Urology, and Vascular Surgery. Aetna members in the
designated counties must choose Aexcel designated specialists or they will
incur out-of-network charges. There is no additional cost when members use
Aexcel specialists. You’ll find them by looking for the star next to the doctors’ names
at www.aetna.com/docfind/custom/advplans or in your printed directory.

* Networks may not be available in all ZIP codes and are subject to change.
** Aetna members in the designated counties must choose Aexcel designated specialists or they will incur out-of-network charges.
HOW DO I MAKE
SMART HEALTH CARE DECISIONS?
Sure, health care options can sometimes This website offers useful tips on different
be confusing. But it’s important to insurance products, plus interactive tools
understand your health and personal that show how big life changes will affect
finance choices, so you can plan your health care options.
ahead and make wise decisions.
PlanforYourHealth.com can help Visit www.geataquickquote.com,
you choose the best health care and get guidance for different stages in
alternatives for you and your family. your life — and in your health.
YOUR MANAGED CHOICE
OPEN ACCESS (MCOA)
PLAN OPTION(S)

ROBUST COVER AGE AND THE FLEXIBILIT Y OF LOWER


MONTHLY PAYMENTS BAL ANCED WITH A DEDUCTIBLE…
WHERE YOU DON’T PAY A LOT FOR FREQUENT
DOCTOR VISITS

FEATURING :
• Robust coverage with a choice of varying deductible levels
63.06.300.1-CA (1/11)
MANAGED CHOICE OPEN ACCESS 1750
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy $750 $750


Individual $1,750 $5,000 Deductible
Family $3,500 $10,000 per individual Does not apply to generic
Coinsurance 30% after deductible up to 50% after deductible up to Generic $15 copay $15 copay
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Oral Contraceptives deductible plus 50%
Included waived deductible
$0 once out-of-pocket max. is satisfied
waived
Coinsurance Maximum
Individual $10,750 $7,500 Preferred Brand $35 copay $35 copay
Family $21,500 $15,000 Oral Contraceptives after deductible plus 50%
Included after deductible
Out-of-Pocket Maximum
Individual $12,500 $12,500 Non-Preferred $60 copay $60 copay
Family $25,000 $25,000 Brand after deductible plus 50%
Oral Contraceptives after deductible
Includes deductible Included
Non-Specialist Office Visit Unlimited visits $40 copay deductible waived 50% after deductible Self-Injectables 25% after Not covered
General Physician, Family Practitioner, deductible
Pediatrician or Internist
* Maximum applies to combined in and
Specialist Visit Unlimited visits $50 copay deductible waived 50% after deductible out-of-network benefits.
** Copay is billed separately and not due at time of
service. Copay does not count towards coinsurance
Hospital Admission 40% after deductible 50% after deductible or out-of-pocket maximum.
Outpatient Surgery 40% after deductible 50% after deductible + Payment for out-of-network facility covered expenses
is determined based on Aetna’s Market Fee Schedule.
Urgent Care Facility $75 copay after deductible 50% after deductible Payment for out-of-network non-facility covered
expenses is determined based on the negotiated
Emergency Room $350 copay** (waived if admitted) charge that would apply if such services were received
from a Network Provider.
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible
Certain areas in California include the Aetna Performance
No waiting period
Network®, which features Aexcel designated specialists
Annual Pap/Mammogram
who have demonstrated cost-effectiveness in the delivery
Maternity Not covered of care and met certain clinical performance measures. The
Except for pregnancy complications Aexcel designation applies to select specialists in 12 specialty
Preventive Health — Routine Physical areas: Cardiology, Cardiothoracic Surgery, Gastroenterology,
$0 copay deductible waived 50% after deductible
No waiting period General Surgery, Obstetrics and Gynecology, Orthopedics,
Includes lab work and X-rays Otolaryngology/ ENT, Neurology, Neurosurgery, Plastic
Surgery, Urology and Vascular Surgery. Aetna members
Lab/X-Ray (Non-Preventive) 30% after deductible 50% after deductible
in the designated counties must choose Aexcel
Skilled Nursing — instead of hospital 40% after deductible 50% after deductible designated specialists or they will incur outof-network
30 days per calendar year* charges. There is no additional cost when members
use Aexcel specialists. You can find them by looking for
Physical/Occupational Therapy 30% after deductible 50% after deductible the star next to the doctor’s names at www.aetna.com/
24 visits per calendar year* docfind/custom/advplans or in your printed directory.

Home Health Care — instead of hospital 30% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment 40% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
MANAGED CHOICE OPEN ACCESS 2750
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy $750 $750


Individual $2,750 $5,500 Deductible
Family $5,500 $11,000 per individual Does not apply to generic
Coinsurance 30% after deductible up to 50% after deductible up to Generic $15 copay $15 copay
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Oral Contraceptives deductible plus 50%
Included waived deductible
$0 once out-of-pocket max. is satisfied
waived
Coinsurance Maximum
Individual $4,750 $7,000 Preferred Brand $35 copay $35 copay
Family $9,500 $14,000 Oral Contraceptives after deductible plus 50%
Included after deductible
Out-of-Pocket Maximum
Individual $7,500 $12,500 Non-Preferred 50% copay 50%
Family $15,000 $25,000 Brand after deductible after deductible
Oral Contraceptives
Includes deductible Included
Non-Specialist Office Visit Unlimited visits $30 copay deductible waived 50% after deductible Self-Injectables 25% after Not covered
General Physician, Family Practitioner, deductible
Pediatrician or Internist

Specialist Visit Unlimited visits $50 copay deductible waived 50% after deductible * Maximum applies to combined in and
out-of-network benefits.
** Copay is billed separately and not due at time of
Hospital Admission 30% after deductible 50% after deductible service. Copay does not count towards coinsurance
or out-of-pocket maximum.
Outpatient Surgery 30% after deductible 50% after deductible + Payment for out-of-network facility covered expenses
is determined based on Aetna’s Market Fee Schedule.
Urgent Care Facility $50 copay after deductible 50% after deductible Payment for out-of-network non-facility covered
Emergency Room $100 copay** (waived if admitted) expenses is determined based on the negotiated
charge that would apply if such services were received
30% coinsurance after deductible
from a Network Provider.
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible
No waiting period Certain areas in California include the Aetna Performance
Annual Pap/Mammogram Network®, which features Aexcel designated specialists
Maternity Not covered who have demonstrated cost-effectiveness in the delivery
Except for pregnancy complications of care and met certain clinical performance measures. The
Aexcel designation applies to select specialists in 12 specialty
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible areas: Cardiology, Cardiothoracic Surgery, Gastroenterology,
No waiting period General Surgery, Obstetrics and Gynecology, Orthopedics,
Includes lab work and X-rays
Otolaryngology/ ENT, Neurology, Neurosurgery, Plastic
Lab/X-Ray (Non-Preventive) 30% after deductible 50% after deductible Surgery, Urology and Vascular Surgery. Aetna members
in the designated counties must choose Aexcel
Skilled Nursing — instead of hospital 30% after deductible 50% after deductible designated specialists or they will incur outof-network
30 days per calendar year* charges. There is no additional cost when members
Physical/Occupational Therapy 30% after deductible 50% after deductible use Aexcel specialists. You can find them by looking for
24 visits per calendar year* the star next to the doctor’s names at www.aetna.com/
docfind/custom/advplans or in your printed directory.
Home Health Care — instead of hospital 30% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment 30% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
MANAGED CHOICE OPEN ACCESS 3500
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy $750 $750


Individual $3,500 $7,000 Deductible
Family $7,000 $14,000 per individual Does not apply to generic
Coinsurance 30% after deductible up to 50% after deductible up to Generic $15 copay $15 copay
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Oral Contraceptives deductible plus 50%
Included waived deductible
$0 once out-of-pocket max. is satisfied
waived
Coinsurance Maximum
Individual $4,000 $5,500 Preferred Brand $35 copay $35 copay
Family $8,000 $11,000 Oral Contraceptives after deductible plus 50%
Included after deductible
Out-of-Pocket Maximum
Individual $7,500 $12,500 Non-Preferred 50% copay 50% copay
Family $15,000 $25,000 Brand after deductible after deductible
Includes deductible Oral Contraceptives
Included
Non-Specialist Office Visit Unlimited visits $35 copay deductible waived 50% after deductible
Self-Injectables 25% after Not covered
General Physician, Family Practitioner,
deductible
Pediatrician or Internist
Specialist Visit Unlimited visits $50 copay deductible waived 50% after deductible
* Maximum applies to combined in and
Hospital Admission 30% after deductible 50% after deductible out-of-network benefits.
** Copay is billed separately and not due at time of
Outpatient Surgery 30% after deductible 50% after deductible service. Copay does not count towards coinsurance
or out-of-pocket maximum.
Urgent Care Facility $50 copay deductible waived 50% after deductible + Payment for out-of-network facility covered
Emergency Room $100 copay** (waived if admitted) expenses is determined based on Aetna’s Market
30% coinsurance after deductible Fee Schedule. Payment for out-of-network non-
facility covered
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible expenses is determined based on the negotiated
No waiting period charge that would apply if such services were
Annual Pap/Mammogram received
from a Network Provider.
Maternity Not covered
Except for pregnancy complications
Certain areas in California include the Aetna Performance
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible Network®, which features Aexcel designated specialists
No waiting period who have demonstrated cost-effectiveness in the delivery
Includes lab work and X-rays
of care and met certain clinical performance measures.
Lab/X-Ray (Non-Preventive) 30% after deductible 50% after deductible The Aexcel designation applies to select specialists
in 12 specialty areas: Cardiology, Cardiothoracic
Skilled Nursing — instead of hospital 30% after deductible 50% after deductible Surgery, Gastroenterology, General Surgery, Obstetrics
30 days per calendar year* and Gynecology, Orthopedics, Otolaryngology/ ENT,
Physical/Occupational Therapy 30% after deductible 50% after deductible Neurology, Neurosurgery, Plastic Surgery, Urology and
24 visits per calendar year* Vascular Surgery. Aetna members in the designated
counties must choose Aexcel designated specialists
or they will incur outof-network charges. There
Home Health Care — instead of hospital 30% after deductible 50% after deductible is no additional cost when members use Aexcel
30 visits per calendar year* specialists. You can find them by looking for the
Durable Medical Equipment 30% after deductible 50% after deductible star next to the doctor’s names at www.aetna.com/
Aetna will pay up to $2,000 per calendar year* docfind/custom/advplans or in your printed directory.

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
MANAGED CHOICE OPEN ACCESS 5000
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy $750 $750


Individual $5,000 $10,000 Deductible
Family $10,000 $20,000 per individual Does not apply to generic
Coinsurance 30% after deductible up to 50% after deductible up to Generic $15 copay $15 copay
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Oral Contraceptives deductible plus 50%
Included waived deductible
$0 once out-of-pocket max. is satisfied
waived
Coinsurance Maximum
Individual $5,000 $2,500 Preferred Brand $35 copay $35 copay
Family $10,000 $5,000 Oral Contraceptives after deductible plus 50%
Included after deductible
Out-of-Pocket Maximum
Individual $10,000 $12,500 Non-Preferred 50% copay 50% copay
Family $20,000 $25,000 Brand after deductible after deductible
Includes deductible Oral Contraceptives
Included
Non-Specialist Office Visit Unlimited visits $40 copay deductible waived 50% after deductible
Self-Injectables 25% after Not covered
General Physician, Family Practitioner,
deductible
Pediatrician or Internist
Specialist Visit Unlimited visits $50 copay deductible waived 50% after deductible
Hospital Admission 30% after deductible 50% after deductible * Maximum applies to combined in and
out-of-network benefits.
Outpatient Surgery 30% after deductible 50% after deductible ** Copay is billed separately and not due at time of
service. Copay does not count towards coinsurance
Urgent Care Facility $50 copay deductible waived 50% after deductible or out-of-pocket maximum.
+ Payment for out-of-network facility covered expenses
Emergency Room $100 copay** (waived if admitted) is determined based on Aetna’s Market Fee Schedule.
30% coinsurance after deductible Payment for out-of-network non-facility covered
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible expenses is determined based on the negotiated
No waiting period charge that would apply if such services were received
Annual Pap/Mammogram from a Network Provider.

Maternity Not covered Certain areas in California include the Aetna Performance
Except for pregnancy complications Network®, which features Aexcel designated specialists
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible who have demonstrated cost-effectiveness in the delivery
No waiting period of care and met certain clinical performance measures. The
Includes lab work and X-rays Aexcel designation applies to select specialists in 12 specialty
30% after deductible 50% after deductible areas: Cardiology, Cardiothoracic Surgery, Gastroenterology,
Lab/X-Ray (Non-Preventive)
General Surgery, Obstetrics and Gynecology, Orthopedics,
Skilled Nursing — instead of hospital 30% after deductible 50% after deductible Otolaryngology/ ENT, Neurology, Neurosurgery, Plastic
30 days per calendar year* Surgery, Urology and Vascular Surgery. Aetna members
in the designated counties must choose Aexcel
Physical/Occupational Therapy 30% after deductible 50% after deductible
designated specialists or they will incur outof-network
24 visits per calendar year* charges. There is no additional cost when members
use Aexcel specialists. You can find them by looking for
Home Health Care — instead of hospital 30% after deductible 50% after deductible the star next to the doctor’s names at www.aetna.com/
30 visits per calendar year* docfind/custom/advplans or in your printed directory.
Durable Medical Equipment 30% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
YOUR HIGH DEDUCTIBLE
PLAN OPTION(S)
LOWER PREMIUM COSTS … AND A HEALTH SAVINGS
ACCOUNT ( HSA) COMPATIBLE PL AN THAT OFFERS
TA X-ADVANTAGED SAVINGS

FEATURING :
• 0% coinsurance in network after your deductible is met
MANAGED CHOICE OPEN ACCESS
HIGH DEDUCTIBLE 3500 (HSA COMPATIBLE)
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy Integrated Medical/Rx Deductible


Individual $3,500 $6,000 Deductible
Family $7,000 $12,000 per individual
Coinsurance 10% after deductible up to 50% after deductible up to Generic 10% after 50% after
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Oral Contraceptives Medical/ Medical/
Included Rx Deductible Rx Deductible
$0 once out-of-pocket max. is satisfied
Preferred Brand 10% after 50% after
Coinsurance Maximum Oral Contraceptives Medical/ Medical/
Individual $2,450 $4,000 Included Rx Deductible Rx Deductible
Family $4,900 $8,000
Non-Preferred Not covered Not covered
Out-of-Pocket Maximum Brand
Individual $5,950 $10,000 Oral Contraceptives
Family $11,900 $20,000 Included
Self Injectibles Not covered Not covered
Includes deductible
Non-Specialist Office Visit Unlimited visits 10% after deductible 50% after deductible
General Physician, Family Practitioner, * Maximum applies to combined in and
Pediatrician or Internist out-of-network benefits.
** Copay is billed separately and not due at time of
Specialist Visit Unlimited visits 10% after deductible 50% after deductible service. Copay does not count towards coinsurance
or out-of-pocket maximum.
Hospital Admission 10% after deductible 50% after deductible + Payment for out-of-network facility covered expenses
is determined based on Aetna’s Market Fee Schedule.
Outpatient Surgery 10% after deductible 50% after deductible Payment for out-of-network non-facility covered
expenses is determined based on the negotiated
Urgent Care Facility 10% after deductible 50% after deductible charge that would apply if such services were received
from a Network Provider.
Emergency Room 10% after deductible
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible Certain areas in California include the Aetna Performance
No waiting period Network®, which features Aexcel designated specialists
Annual Pap/Mammogram who have demonstrated cost-effectiveness in the delivery
of care and met certain clinical performance measures. The
Maternity Not covered Aexcel designation applies to select specialists in 12 specialty
Except for pregnancy complications areas: Cardiology, Cardiothoracic Surgery, Gastroenterology,
General Surgery, Obstetrics and Gynecology, Orthopedics,
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible Otolaryngology/ ENT, Neurology, Neurosurgery, Plastic
No waiting period
Surgery, Urology and Vascular Surgery. Aetna members
Includes lab work and X-rays
in the designated counties must choose Aexcel
Lab/X-Ray (Non-Preventive) 10% after deductible 50% after deductible designated specialists or they will incur outof-network
charges. There is no additional cost when members
Skilled Nursing — instead of hospital 10% after deductible 50% after deductible use Aexcel specialists. You can find them by looking for
30 days per calendar year* the star next to the doctor’s names at www.aetna.com/
Physical/Occupational Therapy docfind/custom/advplans or in your printed directory.
10% after deductible 50% after deductible
24 visits per calendar year*
Home Health Care — instead of hospital 10% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment 10% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change. Investment services are independently
offered by the HSA Administrator.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
MANAGED CHOICE OPEN ACCESS
HIGH DEDUCTIBLE 5500 (HSA COMPATIBLE)
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy Integrated Medical/Rx Deductible


Individual $5,500 $10,000 Deductible
Family $11,000 $20,000 per individual
Coinsurance 0% after deductible up to 50% after deductible up to Generic 0% after 50% after
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Oral Contraceptives Medical/ Medical/
Included Rx Deductible Rx Deductible
$0 once out-of-pocket max. is satisfied
Preferred Brand 0% after 50% after
Coinsurance Maximum Oral Contraceptives Medical/ Medical/
Individual $0 $2,500 Included Rx Deductible Rx Deductible
Family $0 $5,000
Non-Preferred Not covered Not covered
Out-of-Pocket Maximum Brand
Individual $5,500 $12,500 Oral Contraceptives
Family $11,000 $25,000 Included
Self-Injectables Not covered Not covered
Includes deductible
Non-Specialist Office Visit Unlimited visits 0% after deductible 50% after deductible
General Physician, Family Practitioner,
Pediatrician or Internist * Maximum applies to combined in and
out-of-network benefits.
Specialist Visit Unlimited visits 0% after deductible 50% after deductible ** Copay is billed separately and not due at time of
Hospital Admission service. Copay does not count towards coinsurance
0% after deductible 50% after deductible or out-of-pocket maximum.
Outpatient Surgery + Payment for out-of-network facility covered expenses
0% after deductible 50% after deductible is determined based on Aetna’s Market Fee Schedule.
Urgent Care Facility Payment for out-of-network non-facility covered
0% after deductible 50% after deductible
expenses is determined based on the negotiated
Emergency Room $0 copay after deductible charge that would apply if such services were received
from a Network Provider.
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible
No waiting period Certain areas in California include the Aetna Performance
Annual Pap/Mammogram Network®, which features Aexcel designated specialists
who have demonstrated cost-effectiveness in the delivery
Maternity Not covered of care and met certain clinical performance measures.
Except for pregnancy complications The Aexcel designation applies to select specialists in
Preventive Health — Routine Physical 12 specialty areas: Cardiology, Cardiothoracic Surgery,
$0 copay deductible waived 50% after deductible
No waiting period Gastroenterology, General Surgery, Obstetrics and
Includes lab work and X-rays Gynecology, Orthopedics, Otolaryngology/ ENT, Neurology,
Neurosurgery, Plastic Surgery, Urology and Vascular
Lab/X-Ray (Non-Preventive) 0% after deductible 50% after deductible Surgery. Aetna members in the designated counties
must choose Aexcel designated specialists or they
Skilled Nursing — instead of hospital 0% after deductible 50% after deductible will incur outof-network charges. There is no
30 days per calendar year* additional cost when members use Aexcel specialists.
Physical/Occupational Therapy 0% after deductible 50% after deductible You can find them by looking for the star next to the
24 visits per calendar year* doctor’s names at www.aetna.com/docfind/custom/
advplans or in your printed directory.
Home Health Care — instead of hospital 0% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment 0% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change. Investment services are independently
offered by the HSA Administrator.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
YOUR VALUE
PLAN OPTION(S)
AFFORDABILIT Y — A BAL ANCE OF LOWER
MONTHLY PREMIUMS AND GREATER COST
SHARING WITH QUALIT Y COVER AGE

FEATURING :
• Coverage for routine and major services with lower monthly premiums
(that’s the “Value” part)
MANAGED CHOICE OPEN ACCESS
VALUE 2500
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy Not Applicable Not Applicable


Individual $2,500 $5,000 Deductible
Family $5,000 $10,000 per individual
Coinsurance 30% after deductible up to 50% after deductible up to
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Generic $20 copay $20 copay
Oral Contraceptives plus 50%
$0 once out-of-pocket max. is satisfied Included
Coinsurance Maximum
Individual $5,000 $5,000 Preferred Brand Not covered Not covered
Family $10,000 $10,000 Oral Contraceptives
Included
Out-of-Pocket Maximum
Individual $7,500 $10,000 Non-Preferred Not covered Not covered
Family $15,000 $20,000 Brand
Includes deductible Oral Contraceptives
Included
Non-Specialist Office Visit Unlimited visits $50 copay, deductible waived 50% after deductible
General Physician, Family Practitioner, For visits 1-3 4+ visits member Self-Injectables Not covered Not covered
Pediatrician or Internist is responsible for 100%.
Aetna discount applies; Aetna
will pay 100% after OOP is * Maximum applies to combined in and
satisfied NOTE non-spec and out-of-network benefits.
spec do not share visits ** Copay is billed separately and not due at time of
Specialist Visit Unlimited visits $50 copay, deductible waived 50% after deductible service. Copay does not count towards coinsurance
or out-of-pocket maximum.
For visits 1-3 4+ visits member
+ Payment for out-of-network facility covered expenses
is responsible for 100%. is determined based on Aetna’s Market Fee Schedule.
Aetna discount applies; Aetna Payment for out-of-network non-facility covered
will pay 100% after OOP is expenses is determined based on the negotiated
satisfied NOTE non-spec and charge that would apply if such services were received
spec do not share visits from a Network Provider.
Hospital Admission 40% after deductible 50% after deductible
Certain areas in California include the Aetna Performance
Outpatient Surgery 40% after deductible 50% after deductible
Network®, which features Aexcel designated specialists
Urgent Care Facility $75 copay deductible waived 50% after deductible who have demonstrated cost-effectiveness in the delivery
of care and met certain clinical performance measures. The
Emergency Room $100 copay** (waived if admitted)
Aexcel designation applies to select specialists in 12 specialty
30% coinsurance after deductible
areas: Cardiology, Cardiothoracic Surgery, Gastroenterology,
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible General Surgery, Obstetrics and Gynecology, Orthopedics,
No waiting period Otolaryngology/ ENT, Neurology, Neurosurgery, Plastic
Annual Pap/Mammogram Surgery, Urology and Vascular Surgery. Aetna members
Maternity Not covered in the designated counties must choose Aexcel
Except for pregnancy complications designated specialists or they will incur outof-network
charges. There is no additional cost when members
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible use Aexcel specialists. You can find them by looking for
No waiting period Includes lab work and X-rays the star next to the doctor’s names at www.aetna.com/
docfind/custom/advplans or in your printed directory.
Lab/X-Ray (Non-Preventive) 30% after deductible 50% after deductible
Skilled Nursing — instead of hospital 40% after deductible 50% after deductible
30 days per calendar year*
Physical/Occupational Therapy 30% after deductible 50% after deductible
24 visits per calendar year*
Home Health Care — instead of hospital 30% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment 40% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
MANAGED CHOICE OPEN ACCESS
VALUE 5000
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy Not Applicable Not Applicable


Individual $5,000 $10,000 Deductible
Family $10,000 $20,000 per individual
Coinsurance 30% after deductible up to 50% after deductible up to
(Member’s responsibility) Generic $20 copay $20 copay
out-of-pocket max. out-of-pocket max.
Oral Contraceptives plus 50%
$0 once out-of-pocket max. is satisfied Included
Coinsurance Maximum
Preferred Brand Not covered Not covered
Individual $5,000 $2,500
Oral Contraceptives Aetna Discount
Family $10,000 $5,000
Included Applies
Out-of-Pocket Maximum
Individual $10,000 $12,500 Non-Preferred Not covered Not covered
Family $20,000 $25,000 Brand Aetna Discount
Oral Contraceptives Applies
Includes deductible Included
Non-Specialist Office Visit Unlimited visits $50 copay, deductible waived 50% after deductible
General Physician, Family Practitioner, For visits 1-3 4+ visits member Self-Injectables Not covered Not covered
Pediatrician or Internist is responsible for 100%. Aetna
discount applies; Aetna will pay
100% after OOP is satisfied
NOTE non-spec and spec do * Maximum applies to combined in and
not share visits out-of-network benefits.
** Copay is billed separately and not due at time of
Specialist Visit Unlimited visits $50 copay, deductible waived 50% after deductible service. Copay does not count towards coinsurance
For visits 1-3 4+ visits member or out-of-pocket maximum.
is responsible for 100%. Aetna + Payment for out-of-network facility covered expenses
discount applies; Aetna will pay is determined based on Aetna’s Market Fee Schedule.
100% after OOP is satisfied Payment for out-of-network non-facility covered
NOTE non-spec and spec do expenses is determined based on the negotiated
not share visits charge that would apply if such services were received
from a Network Provider.
Hospital Admission 40% after deductible 50% after deductible
Outpatient Surgery 40% after deductible 50% after deductible Certain areas in California include the Aetna Performance
Urgent Care Facility $75 copay deductible waived 50% after deductible Network®, which features Aexcel designated specialists
who have demonstrated cost-effectiveness in the delivery
Emergency Room $100 copay** (waived if admitted) of care and met certain clinical performance measures. The
30% coinsurance after deductible Aexcel designation applies to select specialists in 12 specialty
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible areas: Cardiology, Cardiothoracic Surgery, Gastroenterology,
No waiting period General Surgery, Obstetrics and Gynecology, Orthopedics,
Annual Pap/Mammogram Otolaryngology/ ENT, Neurology, Neurosurgery, Plastic
Surgery, Urology and Vascular Surgery. Aetna members
Maternity Not covered in the designated counties must choose Aexcel
Except for pregnancy complications designated specialists or they will incur outof-network
charges. There is no additional cost when members
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible use Aexcel specialists. You can find them by looking for
No waiting period the star next to the doctor’s names at www.aetna.com/
Includes lab work and X-rays
docfind/custom/advplans or in your printed directory.
Lab/X-Ray (Non-Preventive) 30% after deductible 50% after deductible
Skilled Nursing — instead of hospital 40% after deductible 50% after deductible
30 days per calendar year*
Physical/Occupational Therapy 30% after deductible 50% after deductible
24 visits per calendar year*
Home Health Care — instead of hospital 30% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment 40% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
MANAGED CHOICE OPEN ACCESS
VALUE 8000
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy Not Applicable Not Applicable


Individual $8,000 $10,000 Deductible
Family $16,000 $20,000 per individual
Coinsurance 30% after deductible up to 50% after deductible up to
(Member’s responsibility) Generic $20 copay $20 copay
out-of-pocket max. out-of-pocket max.
Oral Contraceptives plus 50%
$0 once out-of-pocket max. is satisfied Included
Coinsurance Maximum
Preferred Brand Not covered Not covered
Individual $4,500 $2,500
Oral Contraceptives
Family $9,000 $5,000
Included
Out-of-Pocket Maximum
Individual $12,500 $12,500 Non-Preferred Not covered Not covered
Family $25,000 $25,000 Brand
Oral Contraceptives
Includes deductible Included
Non-Specialist Office Visit Unlimited visits $50 copay, deductible waived 50% after deductible
General Physician, Family Practitioner, For visits 1-3; 4+ visits member Self-Injectables Not covered Not covered
Pediatrician or Internist is responsible for 100%. Aetna
discount applies; Aetna will pay
100% after OOP is satisfied
NOTE non-spec and spec do * Maximum applies to combined in and
not share visits out-of-network benefits.
** Copay is billed separately and not due at time of
Specialist Visit Unlimited visits $50 copay, deductible waived 50% after deductible service. Copay does not count towards coinsurance
For visits 1-3; 4+ visits member or out-of-pocket maximum.
is responsible for 100%. Aetna + Payment for out-of-network facility covered expenses
discount applies; Aetna will pay is determined based on Aetna’s Market Fee Schedule.
100% after OOP is satisfied Payment for out-of-network non-facility covered
NOTE non-spec and spec do expenses is determined based on the negotiated
not share visits charge that would apply if such services were received
from a Network Provider.
Hospital Admission 40% after deductible 50% after deductible
Outpatient Surgery 40% after deductible 50% after deductible Certain areas in California include the Aetna Performance
Urgent Care Facility $75 copay deductible waived 50% after deductible Network®, which features Aexcel designated specialists
who have demonstrated cost-effectiveness in the delivery
Emergency Room $100 copay** (waived if admitted) of care and met certain clinical performance measures. The
30% coinsurance after deductible Aexcel designation applies to select specialists in 12 specialty
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible areas: Cardiology, Cardiothoracic Surgery, Gastroenterology,
No waiting period General Surgery, Obstetrics and Gynecology, Orthopedics,
Annual Pap/Mammogram Otolaryngology/ ENT, Neurology, Neurosurgery, Plastic
Surgery, Urology and Vascular Surgery. Aetna members
Maternity Not covered in the designated counties must choose Aexcel
Except for pregnancy complications designated specialists or they will incur outof-network
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible charges. There is no additional cost when members
No waiting period use Aexcel specialists. You can find them by looking for
Includes lab work and X-rays
the star next to the doctor’s names at www.aetna.com/
Lab/X-Ray (Non-Preventive) 30% after deductible 50% after deductible docfind/custom/advplans or in your printed directory.
Skilled Nursing — instead of hospital 40% after deductible 50% after deductible
30 days per calendar year*
Physical/Occupational Therapy 30% after deductible 50% after deductible
24 visits per calendar year*
Home Health Care — instead of hospital 30% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment 40% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
YOUR PREVENTIVE
AND HOSPITAL CARE
PLAN OPTION(S)
AFFORDABILIT Y IS ONE OF YOUR TOP PRIORITIES
AND YOU USE ONLY BASIC HEALTH CARE SERVICES …
AND WANT TO KEEP YOUR MONTHLY PREMIUMS LOWER

FEATURING :
• Coverage for preventive care and major health care services with a lower monthly premium
PREVENTIVE AND HOSPITAL CARE 3000
(HSA COMPATIBLE)
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy Not Applicable Not Applicable


Individual $3,000 $6,000 Deductible
Family $6,000 $12,000 per individual
Coinsurance 20% after deductible up to 50% after deductible up to Generic Not covered Not covered
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Oral Contraceptives
Included
$0 once out-of-pocket max. is satisfied
Preferred Brand Not covered Not covered
Coinsurance Maximum
Oral Contraceptives
Individual $2,000 $4,000
Included
Family $4,000 $8,000
Out-of-Pocket Maximum Non-Preferred Not covered Not covered
Individual $5,000 $10,000 Brand
Family $10,000 $20,000 Oral Contraceptives
Included
Includes deductible
Self-Injectables Not covered Not covered
Non-Specialist Office Visit Not covered Not covered
General Physician, Family Practitioner,
Pediatrician or Internist * Maximum applies to combined in and
out-of-network benefits.
Specialist Visit Not covered Not covered ** Copay is billed separately and not due at time of
Hospital Admission service. Copay does not count towards coinsurance
20% after deductible 50% after deductible
or out-of-pocket maximum.
Outpatient Surgery 20% after deductible 50% after deductible + Payment for out-of-network facility covered
expenses is determined based on Aetna’s Market
Urgent Care Facility Not covered Not covered Fee Schedule. Payment for out-of-network non-
facility covered expenses is determined based on the
Emergency Room $100 copay** (waived if admitted) negotiated charge that would apply if such services
20% coinsurance after deductible were received from a Network Provider.
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible Certain areas in California include the Aetna Performance
No waiting period
Network®, which features Aexcel designated specialists
Annual Pap/Mammogram
who have demonstrated cost-effectiveness in the delivery
Maternity Not covered of care and met certain clinical performance measures.
Except for pregnancy complications The Aexcel designation applies to select specialists
in 12 specialty areas: Cardiology, Cardiothoracic
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible Surgery, Gastroenterology, General Surgery, Obstetrics
No waiting period and Gynecology, Orthopedics, Otolaryngology/ ENT,
Includes lab work and X-rays
Neurology, Neurosurgery, Plastic Surgery, Urology and
Lab/X-Ray (Non-Preventive) Not covered Not covered Vascular Surgery. Aetna members in the designated
counties must choose Aexcel designated specialists
Skilled Nursing — instead of hospital 20% after deductible 50% after deductible or they will incur outof-network charges. There
30 days per calendar year* is no additional cost when members use Aexcel
Physical/Occupational Therapy Not covered Not covered specialists. You can find them by looking for the
24 visits per calendar year* star next to the doctor’s names at www.aetna.com/
docfind/custom/advplans or in your printed directory.
Home Health Care — instead of hospital 20% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment Not covered Not covered
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change. Investment services are independently
offered by the HSA Administrator.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
INDIVIDUAL DENTAL
PPO MAX PLAN
PLAN OPTION
INDIVIDUAL DENTAL PPO MAX PLAN
C A LI FO R NIA
A E TNA A D VANTAGE PLAN OP T IONS
Get a Quote or Apply Online www.GetaQuickQuote.com

MEMBER BENEFITS Preferred Non-Preferred


Participating dentists may offer discounted rates
Annual Deductible per Member $25; $25; on additional services such as tooth whitening.
(Does not apply to Diagnostic $75 family maximum $75 family maximum Discounts for non-covered services may not be
and Preventive Services) available in all states.
Annual Maximum Benefit Unlimited Unlimited Nonpreferred (Out-of-Network) Coverage is limited to a
maximum of the Plan’s payment, which is based on the
DIAGNOSTIC SERVICES contracted maximum fee for participating providers in the
particular geographic area.
Oral exams
Above list of covered services is representative. A summary
Periodic oral exam 100% deductible waived 50% deductible waived of exclusions is listed in the Aetna Advantage Plan
brochure. For a full list of benefit coverage and exclusions
Comprehensive oral exam 100% deductible waived 50% deductible waived refer to the plan documents.
Problem-focused oral exam 100% deductible waived 50% deductible waived All products not available in all counties.

X-rays This material is for information only. Dental insurance


plans contain exclusions and limitations. Not all dental
Bitewing — single film 100% deductible waived 50% deductible waived services are covered. See plan documents for a complete
description of benefits, exclusions, limitations and
Complete series 100% deductible waived 50% deductible waived conditions of coverage. Plan features and availability may
vary by location and are subject to change. Information is
PREVENTIVE SERVICES believed to be accurate as of the production date; however,
it is subject to change.
Adult cleaning 100% deductible waived 50% deductible waived
Aetna Advantage Plans for Individuals, Families and
Child cleaning 100% deductible waived 50% deductible waived the Self-Employed are underwritten by Aetna Life
Insurance Company (Aetna) directly and/or through
Sealants — per tooth Not covered* Not covered an out-of-state blanket trust or Aetna Health Inc. In
some states, individuals may qualify as a business
Fluoride application — with cleaning 100% deductible waived 50% deductible waived group of one and may be eligible for guaranteed
issue, small group health plans. To the extent permitted
Space maintainers Not covered* Not covered
by law, these plans are medically underwritten and you
may be declined coverage in accordance with your
BASIC SERVICES health condition.
Amalgam fillings — 2 surfaces 100% after deductible 50% after deductible * Discounts for non-covered services may not be available
in all states.
Resin fillings — 2 surfaces Not covered* Not covered

Oral Surgery

Extraction — exposed root or erupted tooth Not covered* Not covered

Extraction of impacted tooth — soft tissue Not covered* Not covered

MAJOR SERVICES
Complete upper denture Not covered* Not covered
Partial upper denture (resin based) Not covered* Not covered

Crown — Porcelain with noble metal Not covered* Not covered


Pontic — Porcelain with noble metal Not covered* Not covered
Inlay — Metallic (3 or more surfaces) Not covered* Not covered
Oral Surgery
Removal of impacted tooth — partially bony Not covered* Not covered
Endodontic Services
Bicuspid root canal therapy Not covered* Not covered
Molar root canal therapy Not covered* Not covered
Periodontic Services

Scaling & root planing — per quadrant Not covered* Not covered
Osseous surgery — per quadrant Not covered* Not covered

ORTHODONTIC SERVICES Not covered* Not covered

63.06.300.1-CA (1/11)
YOUR MANAGED CHOICE
OPEN ACCESS (MCOA)
7500 WITH UNLIMITED PRIMARY
CARE VISITS PLUS DENTAL
PLAN OPTION
MEDIC AL AND DENTAL COVER AGE
BUNDLED TOGETHER ... AT A REASONABLE COST

FEATURING :
• Our only plan that offers one monthly payment for medical and dental insurance coverage;
and you still have access to vision discounts
MANAGED CHOICE OPEN ACCESS 7500
WITH UNLIMITED PRIMARY CARE VISITS PLUS DENTAL
C A LIFO R NIA
A E TNA A D VANTAGE P LAN OPTIONS
Get a Quote or Apply Online www.GetaQuickQuote.com

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

Deductible Pharmacy Not Applicable Not Applicable


Individual $7,500 $10,000 Deductible
Family $15,000 $20,000 per individual
Coinsurance 20% after deductible up to 50% after deductible up to Generic $15 copay $15 copay
(Member’s responsibility) out-of-pocket max. out-of-pocket max. Oral Contraceptives plus 50%
Included
$0 once out-of-pocket max. is satisfied
Coinsurance Maximum Preferred Brand Not covered Not covered
Individual $2,500 $2,500 Oral Contraceptives
Family $5,000 $5,000 Included

Out-of-Pocket Maximum Non-Preferred Not covered Not covered


Individual $10,000 $12,500 Brand
Family $20,000 $25,000 Oral Contraceptives
Included
Includes deductible
Self-Injectables Not covered Not covered
Non-Specialist Office Visit Unlimited visits $40 copay deductible waived 50% after deductible
General Physician, Family Practitioner,
Pediatrician or Internist * Maximum applies to combined in and
Specialist Visit Unlimited visits 20% after deductible 50% after deductible out-of-network benefits.
** Copay is billed separately and not due at time of
Hospital Admission 20% after deductible 50% after deductible service. Copay does not count towards coinsurance
or out-of-pocket maximum.
Outpatient Surgery 20% after deductible 50% after deductible + Payment for out-of-network facility covered expenses
is determined based on Aetna’s Market Fee Schedule.
Urgent Care Facility $75 copay deductible waived 50% after deductible Payment for out-of-network non-facility covered
Emergency Room $150 copay** (waived if admitted) expenses is determined based on the negotiated
after deductible charge that would apply if such services were received
from a Network Provider.
Annual Routine Gyn Exam $0 copay deductible waived 50% after deductible
No waiting period Certain areas in California include the Aetna Performance
Annual Pap/Mammogram Network®, which features Aexcel designated specialists
Maternity Not covered who have demonstrated cost-effectiveness in the delivery
Except for pregnancy complications of care and met certain clinical performance measures. The
Aexcel designation applies to select specialists in 12 specialty
Preventive Health — Routine Physical $0 copay deductible waived 50% after deductible areas: Cardiology, Cardiothoracic Surgery, Gastroenterology,
No waiting period General Surgery, Obstetrics and Gynecology, Orthopedics,
Includes lab and X-rays
Otolaryngology/ ENT, Neurology, Neurosurgery, Plastic
Lab/X-Ray (Non-Preventive) 20% after deductible 50% after deductible Surgery, Urology and Vascular Surgery. Aetna members
in the designated counties must choose Aexcel
Skilled Nursing — instead of hospital 20% after deductible 50% after deductible
designated specialists or they will incur outof-network
30 days per calendar year*
charges. There is no additional cost when members
Physical/Occupational Therapy 20% after deductible 50% after deductible use Aexcel specialists. You can find them by looking for
24 visits per calendar year* the star next to the doctor’s names at www.aetna.com/
docfind/custom/advplans or in your printed directory.
Home Health Care — instead of hospital 20% after deductible 50% after deductible
30 visits per calendar year*
Durable Medical Equipment 20% after deductible 50% after deductible
Aetna will pay up to $2,000 per calendar year*

This material is for information only. A summary of exclusions is listed in the Aetna Advantage Plan brochure. For a
full list of benefit coverage and exclusions refer to the plan documents. Plans may be subject to medical underwriting
or other restrictions. Rates and benefits vary by location. 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. Health insurance plans contain exclusions and limitations. Information is believed
to be accurate as of the production date: however, it is subject to change.
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. To the extent permitted by law, these plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
63.06.300.1-CA (1/11)
THINGS YOU
NEED TO KNOW

To qualify for an Aetna Advantage M E DI C AL UNDE RW R I T I NG Y O UR P R E MI UM


Plan, you must be: RE QU I R E ME NT S PAY ME NT S
• At least age 19 and under age 64 3/4 Your premium rate is guaranteed for
The Aetna Advantage Plans are not
(If applying as a couple, both you and the initial 12 months of your policy
guaranteed issue plans and require
your spouse must be at least age 19 provided that there are no changes
medical underwriting. Some individuals
and under 64 3/4) to your policy, including your area of
may qualify as eligible under the Health
• Legal residents in a state with Insurance Portability Accountability Act residence, benefit plan or addition
products offered by the Aetna (HIPAA) for guaranteed issue plans. of dependents. However, if there is a
Advantage Plans change in law or regulation or a judicial
All applicants, enrolling spouses and
• Legal U.S. residents for at least six decision that has an impact on the
dependents are subject to medical
continuous months cost of providing your covered benefits
underwriting to determine eligibility
under your policy, we reserve the right
If you qualify for an Aetna Advantage and appropriate premium rate level.
to change your premium rate during
Plan, we offer dependent coverage under
We offer various premium rate levels this guarantee period.
your policy for dependent children up to
based on the medical underwriting of
age 26 (except in Florida and Nebraska,
each applicant.
where dependent coverage is up to
age 30; and in Ohio, where dependent
coverage is up to age 28).
63.44.316.1-CA (1/11)
10 -DAY RIGHT TO REVIEW YOUR COVERAGE
Do not cancel your current insurance until you are notified that you have been REMAINS IN EFFECT AS
accepted for coverage. We’ll review your enrollment form or application to determine
if you meet underwriting requirements. If your application or enrollment form is
LONG AS YOU PAY THE
denied, you’ll be notified by mail. If your application or enrollment form is approved, REQUIRED PREMIUM
you’ll be notified by mail and sent an Aetna Advantage Plan contract and ID card.
CHARGES ON TIME,
If, after reviewing the contract, you find that you’re not satisfied for any reason, simply
return the contract to us within 10 days. We will refund any premium you’ve paid AND AS LONG AS YOU
(including any contract fees or other charges) less the cost of any medical or dental MAINTAIN ELIGIBILITY IN
services paid on behalf of you or any covered dependent.
THE PLAN.

CO NVENIENT Rejected transactions: If the EFT Y O UR C O V E R AG E


P R EMIUM PAYMENT S (checking account) or credit card Your coverage remains in effect as
You can make simple automatic payment rejects for any reason, we long as you pay the required premium
payments via Electronic Funds Transfer will send you a letter requesting charges on time, and as long as
(EFT) or by Visa, MasterCard or American corrected information. If we receive you maintain eligibility in the plan.
Express credit cards. corrected information, you will have Coverage will be terminated if you
the full amount due debited on the become ineligible due to any of the
Registration: Complete the payment next billing cycle. If you fail to send following circumstances:
section of the Aetna Advantage Plans corrected information, we will continue • Non-payment of premiums
enrollment form or application. Select to attempt to debit your bank account
the appropriate payment method (EFT • Becoming a resident of a state or
or charge your credit card for the full
or credit card) to approve the automatic location in which Aetna Advantage
amount due. Failure to supply correct
withdrawal of your initial premium and Plans are not available
account information may result in
all subsequent premium payments. • Obtaining duplicate coverage
your policy being terminated for non-
(Please note: The initial premium payment payment. • For other reasons permissible by law
is debited UPON APPROVAL of your
Timing: Please note the following Levels of coverage and
application).
dates when automatic payments are enrollment
Invoices: You will not receive a paper processed: These plans are subject to medical
invoice when you are enrolled in EFT. underwriting. To the extent that you
• Payments for Cycle 1 accounts
Payments will appear on your bank are subject to medical underwriting,
(1st of the month effective date):
statement as “Aetna Autodebit the following may occur once we
- EFT (checking accounts) will be
Coverage.” have evaluated your application or
debited between the 3rd and 10th
Terminating: To terminate EFT or the of each month the premium is due. enrollment form:
automatic credit card payment option, • You may be enrolled in your
- Credit Cards will be debited
Aetna requires 10 days written notice selected plan at the lowest rate
between the 5th and 12th of each
before the date your next scheduled available (known as the standard
month the premium is due.
payment is due to be processed. Without premium charge)
• Payments for Cycle 2 accounts (15th
this written notice, your bank account • You may be enrolled in your selected
of the month effective date):
or credit card may be debited for the plan at a higher premium
next month’s premium payment. You - EFT (checking accounts) will be
• You may be declined coverage
would then need to contact us to have debited between the 18th and 23rd
(except for dependents under age 19)
a refund processed to your bank account of each month the premium is due.
or credit card. - Credit Cards will be debited Duplicate coverage
between the 20th and 25th of each If you are currently covered by another
Refunds: To process an EFT refund
month the premium is due. carrier, you must agree to discontinue
(placing money back in member’s
the other coverage before or on the
checking account), we need at least five
effective date of the Aetna Advantage
days after the withdrawal was made
Plan. However, do not cancel your current
to ensure valid payment. Credit card
insurance until you are notified that you
refunds will be returned to the credit
have been accepted for coverage and are
card charged within 3-5 business days
certain that you are keeping your Aetna
from the date it is processed.
Advantage Plan coverage.
LIMITATIONS &
EXCLUSIONS

Medical • Weight control services including Dental


These medical plans do not cover surgical procedures for the treatment Listed below are some of the charges
all health care expenses and include of obesity, medical treatment, and and services for which our dental
exclusions and limitations. You should weight control/loss programs plans do not provide coverage.
refer to your plan documents to • Experimental and investigational For a complete list of exclusions and
determine which health care services procedures, (except for coverage for limitations, refer to plan documents.
are covered and to what extent. medically necessary routine patient • Dental services or supplies that are
care costs for members participating primarily used to alter, improve or
The following is a partial list of
in a cancer clinical trial) enhance appearance (negotiated
services and supplies that are generally
• Charges in connection with rates for cosmetic procedures may
not covered. However, your plan
pregnancy care other than for be available when a participating
documents may contain exceptions to
pregnancy complications (unless dentist is accessed)
this list based on state mandates or
otherwise mandated by your state) • Experimental services, supplies
the plan design or rider(s). Services and
• Immunizations for travel or work or procedures
supplies that are generally not covered
• Implantable drugs and certain • Treatment of any jaw joint disorder,
include, but are not limited to:
injectable drugs including injectable such as temporomandibular
• All medical and hospital services not infertility drugs joint disorder
specifically covered in, or which are • Orthotics • Replacement of lost or stolen appliances
limited or excluded by your plan • Radial keratotomy or related procedures and certain damaged appliances
documents, including costs of services • Reversal of sterilization • Services that Aetna defines as not
before coverage begins and after • Services, supplies or counseling related necessary for the diagnosis, care or
coverage terminates to the treatment of sexual dysfunction treatment of a condition involved
• Cosmetic surgery • Special or private duty nursing • All other limitations and exclusions in
• Custodial care • Therapy or rehabilitation other
• Donor egg retrieval your plan documents
than those listed as covered in the
• Infertility services and other related plan documents Other information:
reproductive services unless specifically • Mental health and substance abuse In 2009, the ratio of incurred claims
listed as covered in your plan documents coverage (unless otherwise mandated to earned premiums for Aetna Life
• Over-the-counter medications by your state) Insurance Company in California
and supplies was 92.2%.

PRE-EXISTING CONDITIONS
For Applicants 19 and older: 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.

* Six months in California


** 90 days in Alaska, Colorado and Wyoming; 120 days in Connecticut
WANT TO MAKE THE MOST OF YOUR
MONEY? THE MORE YOU KNOW,
THE BETTER IT GETS.
Compare and save with the No matter where you are or what time of • Access the comparison feature so you
Member Payment Estimator day, we’ve designed helpful and practical can shop around
Before thinking about health care services, tools to make your life a little easier. It’s • Get ready for your upcoming procedure
you should know what they will cost. what we call people care. with helpful advice
With this tool, you can find out what • Review costs for tests and procedures
you’ll be paying, what you’re getting by type and locations Explore a smarter health plan.
and what you can expect when you have Visit us at www.aetna.com.
• See cost details based on your health
office visits or tests. By planning ahead, insurance plan, including copays and
you can get the most from your money. deductibles
IMPORTANT DISCLOSURE
INFORMATION FOR CALIFORNIA
FOR MANAGED CHOICE ®, ELECT CHOICE ®, OPEN CHOICE ®
AND AETNA OPEN ACCESS ® PL ANS.

P LAN BENEF ITS • Copay – This may be a flat fee that you HAVE A
The plan you choose is underwritten or pay directly to the health care provider
administered by Aetna Life Insurance at the time of service. STUDENT PL AN?
Company, 151 Farmington Avenue, • Coinsurance – This is a percentage
Hartford, CT 06156, 1-888-982-3862. of the fees that you must pay toward
Covered services include most types the cost of some covered medical
of treatment provided by primary care expenses. Your health care provider If you have a Student Accident
physicians, specialists and hospitals. will bill you for this amount. and Sickness plan please visit
However, a health plan excludes and/ www.aetnastudenthealth.com for
• Calendar Year Deductible – The amount
or includes limits on coverage for some questions or call Aetna Student Health
of covered medical expenses you pay
services, including but not limited to, at the toll-free number on
each calendar year before benefits are
cosmetic surgery and experimental your ID card for more information.
paid. There is a calendar-year deductible
procedures. In addition, in order to For appeals, please forward your
that applies to each person.
be covered, all services, including the request to Chickering Claims
location (type of facility), duration and • Inpatient Hospital Deductible – The Administrators, Inc.*, P.O. Box 15717,
costs of services, must be medically amount of covered inpatient hospital Boston, MA 02215-0014. Fully
necessary as defined below and as expenses you pay for each hospital insured student health insurance
determined by Aetna. The information confinement before benefits are paid. plans are underwritten by Aetna
that follows provides general information This deductible is in addition to any Life Insurance Company (ALIC)
regarding Aetna health plans. For a other copayments or deductibles under and administered by Chickering
complete description of the benefits your plan. Claims Administrators, Inc. (CCA).
available to you, including procedures to • Emergency Room Deductible – The Self-insured plans are funded by
follow, exclusions and limitations, refer to amount of covered hospital emergency the applicable school, with claims
your specific plan documents, which may room expenses you pay each year administration services provided by
include the Booklet-certificate, Group before benefits are paid. A separate Chickering Claims Administrators,
Agreement, Group Insurance Certificate, hospital emergency room deductible Inc. Aetna Student Health is the
Group Policy and any applicable riders applies to each visit by a person to a brand name for products and services
and amendments to your plan. hospital emergency room unless the provided by ALIC and CCA.
person is admitted to the hospital as
63.28.300.1-CA (10/10)

MEMBER COST S HARING an inpatient within 24 hours after a


Cost sharing refers to the portion visit to a hospital emergency room.
of medical services that you pay out
The applicability and amount of each
of your own pocket. Refer to your
copay and deductible listed above will be
plan documents to see which of the
described in your plan documents.
following cost-sharing provisions apply
to your plan:

* The Chickering Group refers to an internal business unit of Chickering Claims Administrators, Inc. The Student Plan is underwritten by Aetna Life Insurance Company
and administered by Chickering Claims Administrators, Inc.
YOUR PRIMARY CARE REFE R R AL P O L I C Y • In plans without out-of-network
P HYSICIA N Check your plan documents to see if your benefits, coverage for services from
plan requires PCP referrals for specialty care. nonparticipating providers requires prior
Check your plan documents to see if your
If referrals are required, you must see your authorization by Aetna in addition to
plan requires you to select a primary
PCP first before visiting a specialist or other a special nonparticipating referral from
care physician (PCP). If a PCP is required,
outpatient provider for nonemergency the PCP. When properly authorized,
you must choose a doctor from the Aetna
or nonurgent care. Your PCP will issue a these services are fully covered, less the
network. You can look up network doctors
referral for the services needed. applicable cost sharing.
in a printed Aetna Physician Directory,
or visit our DocFind® directory at If you do not get a referral when a referral • The referral (and a precertification,
www.aetna.com. If you do not have is required, you may have to pay the bill if required) provides that, except for
Internet access and would like a printed yourself, or the service will be treated as applicable cost sharing (that is, copays,
directory, please contact Member Services nonpreferred if your plan includes out- coinsurance and/or deductibles), you will
at the toll-free number on your ID card of-network benefits. Some services may not have to pay the charges for covered
and request a copy. also require prior approval by us. See the expenses, as long as the individual
Precertification section and your plan seeking care is a member at the time the
You may choose a different PCP for each
documents for details. services are provided.
member of your family. When you enroll,
indicate the name of the PCP you have The following points are important to DI R E C T AC C E S S
chosen on your enrollment form. Or, call remember regarding referrals. O B / GY N P R O GR A M
Member Services after you enroll to tell us
• The referral is how your PCP arranges This program allows female members to
your selection. The name of your PCP will
for you to be covered at the in-network visit without a referral any participating
appear on your Aetna ID card. You may
benefit level for necessary, appropriate obstetrician or gynecologist for a routine
change your selected PCP at any time. If
specialty care and follow-up treatment. breast exam, mammogram and a Pap
you change your PCP, you will receive a
• You should discuss the referral with your smear, and for obstetric or gynecologic
new ID card.
PCP to understand what specialist services problems. Obstetricians and gynecologists
Your PCP can provide primary health care may also refer a woman directly to
are being recommended and why.
services as well as coordinate your overall other participating providers for covered
care. You should consult your PCP when • If the specialist recommends any obstetric or gynecologic services. All health
you are sick or injured to help determine additional treatments or tests beyond plan preauthorization and coordination
the care that is needed. If your plan those referred by the PCP, you may need requirements also apply. If your Ob/Gyn is
requires referrals, your PCP should issue to get another referral from your PCP part of an Independent Practice Association
a referral to a participating specialist or before receiving the services. (IPA), a Physician Medical Group (PMG),
facility for certain services. (See Referral • Except in emergencies, all inpatient an Integrated Delivery System (IDS) or a
Policy for details.) hospital services require a prior referral similar organization, your care must be
from your PCP and prior authorization by coordinated through the IPA, the PMG or
Aetna. similar organization and that organization
may have different referral policies.
• Referrals are valid for one year as long
as you remain an eligible member of the
plan; the first visit must be within 90 days
of referral issue date.

PRODUCT PCP REFERRALS PRECERTIFICATION


REQUIRED? REQUIRED? REQUIRED?
Open Choice No No Yes

Managed Choice Yes Yes Yes

Aetna Open Access Managed Choice Encouraged No Yes

Elect Choice Yes Yes Yes

Aetna Open Access Elect Choice Encouraged N/A Yes


P R ECERTIFICAT ION HE ALT H C AR E P R O V I DE R You can create an advance directive in
Some health care services, like NE T W O R K several ways:
hospitalization and certain outpatient All hospitals may not be considered Aetna • Get an advance medical directive form
surgery, require “precertification.” This participating providers for all the services from a health care professional. Certain
means the service must be approved by that you need. Your physician can contact laws require health care facilities that
Aetna before it will be covered under Aetna to identify a participating facility receive Medicare and Medicaid funds
the plan. Check your plan documents for your specific needs. Certain PCPs are to ask all patients at the time they
for a complete list of services that affiliated with IDSs, IPAs or other provider are admitted if they have an advance
require this approval. When reviewing a groups. If you select one of these PCPs you directive. You don’t need an advance
precertification request, we will verify your will generally be referred to specialists and directive to receive care. But we are
eligibility and make sure the service is a hospitals within that system, association required by law to give you the chance
covered expense under your plan. We also or group (“organization”). However, if to create one.
check the cost-effectiveness of the service your medical needs extend beyond the • Ask for an advance directive form at
and we may communicate with your scope of the affiliated providers, you may state or local offices on aging, bar
doctor if necessary. If you qualify, we may request coverage for services provided associations, legal service programs, or
enroll you in one of our case management by Aetna network providers that are your local health department.
programs and have a nurse call to make not affiliated with the organization. In
sure you understand your upcoming • Work with a lawyer to write an advance
order to be covered, services provided by
procedure. directive.
network providers that are not affiliated
When you visit a doctor, hospital or other with the organization may require prior • Create an advance directive using
provider that participates in the Aetna authorization from Aetna and/or the IDS computer software designed for this
network, someone at the provider’s office or other provider groups. You should purpose.
will contact Aetna on your behalf to get note that other health care providers (e.g. • If you are not satisfied with the way
the approval. specialists) may be affiliated with other Aetna handles advance directives,
providers through organizations. you can file a complaint with your
If your plan allows you to go outside the
Aetna network of providers, you will have For up-to-date information about how to Medicare State Certification Agency.
to get that approval yourself. In this case, locate inpatient and outpatient services, Visit www.medicare.gov for
it is your responsibility to make sure the partial hospitalization and other behavioral information on specific state agencies or
service is precertified, so be sure to talk health care services, please visit our call 1-800-MEDICARE (1-800-633-4227)
to your doctor about it. If you do not get DocFind directory at www.aetna.com. (TTY/TDD: 1-877-486-2048).
proper authorization for out-of-network If you do not have Internet access and Source: American Academy of Family
services, you may have to pay for the would like a printed provider directory, Physicians. Advanced Directives and Do
service yourself. please contact Member Services at the toll- Not Resuscitate Orders. January 2009.
free number on your Aetna ID card and Available at http://familydoctor.org/003.
You cannot request precertification after
request a copy. xml?printxml. Accessed February 20,
the service is performed. To precertify
services, call the number shown on your 2009.
ADVANC E DI R E C T I V E S
Aetna ID card. In plans that do not have
There are three types of advance directives: T R ANS P L ANT S A N D O T H E R
out-of-network benefits, coverage for
services from nonparticipating providers • Durable power of attorney – appoints C O MP L E X C O NDI T I O N S
requires prior authorization by Aetna in someone you trust to make medical Our National Medical Excellence Program®
addition to a special nonparticipating decisions for you. and other specialty programs help you
referral from the PCP. When properly access covered services for transplants and
• Living will – spells out the type and
authorized, these services are fully covered, certain other complex medical conditions
extent of care you want to receive.
less the applicable cost sharing. at participating facilities experienced in
• Do-not-resuscitate order – states that performing these services. Depending on
you don’t want to be given CPR if your the terms of your plan of benefits, you
heart stops or be intubated if you stop may be limited to only those facilities
breathing. participating in these programs when
needing a transplant or other complex
condition covered.
Note: There are exceptions depending on
state requirements.
E M ERGEN CY CARE After-Hours Care Covered nonformulary prescription drugs
You may call your provider’s office 24 may be subject to higher copayments or
If you need emergency care, you are
hours a day, 7 days a week if you have coinsurance under some benefit plans.
covered 24 hours a day, 7 days a week,
medical questions or concerns. You may Some prescription drug benefit plans
anywhere in the world. An emergency
also consider visiting participating Urgent may exclude from coverage certain
medical condition is one manifesting
Care facilities. See your plan documents nonformulary drugs that are not listed on
itself by acute symptoms of sufficient
for cost-sharing provisions for urgent the preferred drug list. If it is medically
severity such that a prudent person, who
care services. necessary for you to use such drugs,
possesses average knowledge of health
your physician, you or your authorized
and medicine, could reasonably expect the P RES C R I P T I O N DR UGS representative (or pharmacist in the case
absence of immediate medical attention
If your plan covers outpatient prescription of antibiotics and analgesics) may contact
to result in serious jeopardy to the person’s
drugs, your plan may include a Aetna to request coverage as a medical
health, or with respect to a pregnant
preferred drug list (also known as a exception. Check your plan documents for
woman, the health of the woman and her
“drug formulary”). The preferred drug details.
unborn child. Whether you are in or out of
list includes prescription drugs that,
an Aetna service area, we simply ask that In addition, certain drugs may require
depending on your prescription drug
you follow the guidelines below when you precertification or step therapy before they
benefits plan, are covered on a preferred
believe you need emergency care. will be covered under some prescription
basis. Many drugs, including many of
drug benefit plans. Step therapy is
• Call the local emergency hotline (ex. 911) those listed on the preferred drug list, are
a different form of precertification
or go to the nearest emergency facility. If subject to rebate arrangements between
that requires a trial of one or more
a delay would not be detrimental to your Aetna and the manufacturer of the drugs.
“prerequisite-therapy” medications
health, call your doctor or PCP. Notify Such rebates are not reflected in and
before a “steptherapy” medication will
your doctor or PCP as soon as possible do not reduce the amount you pay to
be covered. If it is medically necessary for
after receiving treatment. your pharmacy for a prescription drug.
you to use a medication subject to these
• If you are admitted to an inpatient In addition, in circumstances where your
requirements prior to completing the
facility, you or a family member or friend prescription plan utilizes copayments or
step therapy, your physician, you or your
on your behalf should notify your doctor, coinsurance calculated on a percentage
authorized representative can request
PCP or Aetna as soon as possible. of the cost of a drug or a deductible,
coverage of such drug as a medical
it is possible for your cost to be higher
What to do outside your Aetna exception.
for a preferred drug than it would for
service area a nonpreferred drug. For information In addition, some benefit plans include
If you are traveling outside your Aetna regarding how medications are reviewed a mandatory generic drug cost-sharing
service area or if you are a student who and selected for the preferred drug list, requirement. In these plans, you may
is away at school, you are covered for please refer to www.aetna.com or the be required to pay the difference in cost
emergency and urgently needed care. Aetna Preferred Drug (Formulary) Guide. between a covered brand-name drug and
Urgent care may be obtained from a Printed Preferred Drug Guide information its generic equivalent in addition to your
private practice physician, a walk-in clinic, will be provided upon request or, if copayment if you obtain the brand-name
an urgent care center or an emergency applicable, annually for current members drug. Nonprescription drugs and drugs
facility. Certain conditions, such as and upon enrollment for new members. in the Limitations and Exclusions section
bleeding, severe vomiting or fever, are For more information, call Member of the plan documents (received and/
considered “urgent care” outside your Services at the toll-free number on your or available upon enrollment) are not
Aetna service area and are covered in any ID card. The medications listed on the covered, and medical exceptions are not
of the above settings. preferred drug list are subject to change in available for them.
If, after reviewing information submitted accordance with applicable state law. Depending on the plan selected, new
to us by the provider that supplied care, Your prescription drug benefit is generally prescription drugs not yet reviewed for
the nature of the urgent or emergency not limited to drugs listed on the preferred possible addition to the preferred drug list
problem does not qualify for coverage, drug list. Medications that are not listed are either available at the highest copay
we may ask you for more information on the preferred drug list (nonpreferred under plans with an “open” formulary, or
to qualify the coverage. We will send or nonformulary drugs) may be covered excluded from coverage unless a medical
you an Emergency Room Notification subject to the limits and exclusions set exception is obtained under plans that use
Report to complete, or a Member Services forth in your plan documents. a “closed” formulary. These new drugs
representative can take this information may also be subject to precertification or
by telephone. step therapy.
Ask your treating physician(s) about If you have an emergency, call 911 or your HO W AE T NA PAYS I N -
specific medications. Refer to your local emergency hotline, if available. For NE T W O R K P R O V I D E R S
plan documents or contact Member routine services, access covered behavioral All the providers in our network directory
Services for information regarding terms, health services available under your health are independent. They are free to contract
conditions and limitations of coverage. plan by the following methods: with other health plans. Providers join
If you use the Aetna Rx Home Delivery® • Call the toll-free Behavioral Health our network by signing contracts with
mailorder prescription program or the number (where applicable) listed on your us. Or they work for organizations that
Aetna Specialty Pharmacy® specialty drug ID card or, if no number is listed, call the have contracts with us. We pay network
program, you will be acquiring these Member Services number listed on your providers in many different ways.
prescriptions through an affiliate of Aetna. ID card for the appropriate information. Sometimes we pay a rate for a specific
Aetna Rx Home Delivery’s and Aetna service and sometimes for an entire
Specialty Pharmacy’s cost of purchasing • Where required by your plan, call your
course of care (for example, a flat fee for
drugs takes into account discounts, credits PCP for a referral to the designated
a pregnancy without complications). In
and other amounts they may receive from behavioral health provider group.
certain circumstances, some providers are
wholesalers, manufacturers, suppliers and • When applicable, an employee assistance paid a pre-paid amount per month per
distributors. The negotiated charge with or student assistance professional may Aetna member (capitation). We may also
Aetna Rx Home Delivery, LLC. and Aetna refer you to your designated behavioral provide additional incentives to reward
Specialty Pharmacy may be higher than health provider group. physicians for delivering cost-effective
the cost of purchasing drugs and providing quality care.
You can access most outpatient
pharmacy services.
therapy services without a referral or We pay some network hospitals by the
Updates to the Drug Formulary preauthorization. However, you should first day (per diem) and we pay others in a
For up-to-date formulary information, consult Member Services to confirm that different way, such as a percentage of their
visit www.aetna.com/formulary/ or call any such outpatient therapy services do standard billing rates. We encourage you
Member Services at the toll-free number not require a referral or preauthorization. to ask your providers how they are paid for
on your Aetna ID card. If you do not have their services.
Internet access, you may contact Member
BE HAV I O R AL HE ALT H
Services at the toll-free number on your PRO V I DE R S AF E T Y DATA HO W AE T NA PAYS
ID card to find out how a specific drug is AVA I L AB L E O UT-O F -NE T W O R K
covered. For information about our Behavioral P R O V I DE R S
Health provider network safety data, visit Some of our plans pay for services from
BEH AVIORAL HEALT H www.aetna.com/docfind and select the providers who are not in our network.
N ETWO RK “Get info on Patient Safety and Quality” Many plans pay for services based on what
Behavioral health care services are link. If you do not have Internet access, is called the “reasonable,” “usual and
managed by Aetna. As a result, Aetna is you may call Member Services at the customary” or “prevailing” charge. Other
responsible for making initial coverage toll-free number shown on your Aetna plans pay based on our standard fees for
determinations and coordinating referrals ID card to request a printed copy of this care received from a network provider, or
to the Aetna provider network. As with information. based on a percentage of Medicare’s fees.
other coverage determinations, you may When we pay less than what your
appeal adverse behavioral health care BE HAV I O R AL HE ALT H provider charges, your provider may
coverage determinations in accordance DE P R E S S I O N P R E V E NT I O N require you to pay the difference.
with the terms of your health plan. PRO GR AMS This is true even if you have reached
Aetna Behavioral Health offers two your plan’s out-of-pocket maximum.
The type of behavioral health benefits
prevention programs for our members: Here is how we figure out what we will
available to you depends on the terms
Perinatal Depression Education, Screening pay for each type of plan.
of your health plan and state law. If your
and Treatment Referral Program, also
health plan includes behavioral health
known as Beginning Right® Depression
services, you may be covered for mental
Program, and Identification and Referral
health conditions and/or drug and alcohol
of Adolescent Members Diagnosed With
abuse services, including inpatient and
Depression Who Also Have Comorbid
outpatient services, partial hospitalizations
Substance Abuse Needs. For more
and other behavioral health services. You
information on either of these prevention
can determine the type of behavioral
programs and how to use the programs,
health coverage available under the terms
ask Member Services for the phone number
of your plan and how to access services by
of your local Care Management Center.
calling the Aetna Member Services number
listed on your ID card.
Prevailing Charge Plans difference between the prevailing charge Exceptions
($100) and the billed charge ($120). In this Some “prevailing charge” plans set the
Step 1: We review the data.
case, your doctor could bill you for a total prevailing charge at a different percentile.
We get information from Ingenix, which is
of $50. For some claims (like those from hospitals
owned by United HealthCare. Health plans
and outpatient centers) we may use other
send Ingenix copies of claims for services The Prevailing Charge Databases
information and data sources to determine
they received from providers. The claims The New York State Attorney General
the charge.
include the date and place of the service, (NYAG) investigated the conflicts of
the procedure code, and the provider’s interest related to the ownership and use And some of our plans pay based on
charge. Ingenix combines this information of Ingenix data. Under an agreement with a different kind of fee schedule. Also,
into databases that show how much the NYAG, UnitedHealth Group agreed for some non-participating providers
providers charge for just about any service to stop using the Ingenix databases when we may pay based on other contractual
in any zip code. an independent database (not owned by arrangements. Our provider claims codes
a health insurer) is created. In a separate and payment policies may also affect
Step 2: We calculate the portion we pay.
agreement with NYAG in January 2009, what we pay for a claim. Aetna may use
For most of our health plans, we use the
Aetna agreed to use this new database computer software (including ClaimCheck®)
80th percentile to calculate how much to
pay for out-of-network services. Payment when it is ready. We also will work with and other tools to take into account factors
at the 80th percentile means 80 percent the new database owner to create online such as the complexity, amount of time
of charges in the database are the same or tools to give you better information about needed and manner of billing. The effects
less for that service in a particular zip code. the cost of your care when using providers of these policies will be reflected in your
outside our network. Explanation of Benefits documents.
If there are not enough charges (less
Fee Schedule Plans
than 9) in the databases for a service HO W AE T NA PAY S F O R
in a particular zip code, we may use Step 1: We compare the provider’s bill to O UT-O F -NE T W O R K
“derived charge data” instead. “Derived our fee schedule and your health plan. B E HAV I O R AL HEA LT H
charge data” is based on the charges for Your plan may say that we will pay the B E NE F I T S
comparable procedures, multiplied by a provider based on our fee schedule for
We negotiate rates with psychiatrists,
factor that takes into account the relative network doctors, or a certain percentage
psychologists, counselors and other
complexity of the procedure that was of that fee schedule, or a certain
appropriately licensed and credentialed
performed. We also use derived charge percentage of what Medicare pays. For
behavioral health care providers to help
data for our student health plans and example, your plan may say we pay 125
you save money. We refer to these
Aetna Affordable Health Choices® plans. percent of what we pay a network doctor
providers as being “in our network.”
We also may consider other factors to for the same service.
determine what to pay if a service is Let’s say you have your appendix removed. T E C HNO L O GY R EV I E W
unusual or not performed often in your Our network rate for that surgery is We review new medical technologies,
area. These factors can include: $1,600. We multiply $1,600 by 125 behavioral health procedures,
• The complexity of the service percent to get $2,000. We call this the pharmaceuticals and devices to determine
“recognized” or “allowed” amount. which ones should be covered by our
• The degree of skill needed plans. And we even look at new uses for
Step 2: We calculate the portion we pay.
• The provider’s specialty Your plan also says that you must pay existing technologies.
• The prevailing charge in other areas “coinsurance.” This is your share of the To review these innovations, we may:
“recognized” or “allowed” amount.
• Aetna’s own data • Study published medical research and
For example, your share may be 30
scientific evidence on the safety and
Step 3: We refer to your health plan. percent. In that case, we pay 70 percent
effectiveness of medical technologies.
We pay our portion of the prevailing of the $2,000 allowed amount, which is
charge as listed in your health plan. You $1,400. You pay your provider your 30 • Consider position statements and
pay your portion (called “coinsurance”) percent coinsurance, which is $600. Your clinical practice guidelines from medical
and any deductible. For example, your out provider may also ask you to pay the $500 and government groups, including the
of network doctor charges $120 for an difference between the $2,500 bill and federal Agency for Health Care Research
office visit. Your plan covers 70 percent of the $2,000 “recognized” or “allowed” and Quality.
the “reasonable,” “usual and customary” amount. In this case, your provider could • Seek input from relevant specialists and
or “prevailing” charge. Let’s say the bill you $1,100 in total. experts in the technology.
prevailing charge is $100. And let’s say you
already met your deductible. Aetna would • Determine whether the technologies are
pay $70. You would pay the other $30. experimental or investigational.
Your doctor may also bill you for the $20
You can find out more on new tests and Aetna CPBs do not constitute medical We follow specific rules to help us make
treatments in our Clinical Policy Bulletins. advice. Treating providers are solely your health a top concern:
See Clinical Policy Bulletins below for more responsible for medical advice and for your • Aetna employees are not compensated
information. treatment. You should discuss any CPB based on denials of coverage.
related to your coverage or condition with
MEDICA LLY NECE S S ARY your treating provider. While Aetna CPBs • We do not encourage denials of
“Medically necessary” means that the are developed to assist in administering coverage. In fact, our utilization review
service or supply is provided by a physician plan benefits, they do not constitute a staff is trained to focus on the risks of
or other health care provider exercising description of plan benefits. Each benefit members not adequately using certain
prudent clinical judgment for the purpose plan defines which services are covered, services.
of preventing, evaluating, diagnosing or which are excluded, and which are subject Where such use is appropriate, our
treating an illness, injury or disease or to dollar caps or other limits. You and Utilization Review/Patient Management
its symptoms, and that provision of the your providers will need to consult the staff uses nationally recognized guidelines
service or supply is: benefit plan to determine if there are any and resources, such as The Milliman Care
• In accordance with generally accepted exclusions or other benefit limitations Guidelines® to guide the precertification,
standards of medical practice; and applicable to this service or supply. concurrent review and retrospective review
CPBs are regularly updated and are processes. To the extent certain Utilization
• Clinically appropriate in accordance with
therefore subject to change. Aetna CPBs Review/Patient Management functions are
generally accepted standards of medical
are available at www.aetna.com under delegated to IDSs, IPAs or other provider
practice in terms of type, frequency, extent,
“Members” and then “Health Coverage groups (“Delegates”), such Delegates
site and duration, and considered effective
Information.” If you do not have Internet utilize criteria that they deem appropriate.
for the illness, injury or disease; and
access, please contact Member Services at Utilization Review/Patient Management
• Not primarily for the convenience of you, the toll-free number on your ID card for policies may be modified to comply with
or for the physician or other health care information about specific Clinical Policy applicable state law.
provider; and Bulletins. Only medical professionals make decisions
• Not more costly than an alternative service denying coverage for services for reasons
or sequence of services at least as likely UT ILI Z AT I O N R E V I E W / of medical necessity. Coverage denial
to produce equivalent therapeutic or PAT I E NT MANAGE ME NT letters for such decisions delineate any
diagnostic results as to the diagnosis or We have developed a patient management unmet criteria, standards and guidelines,
treatment of the illness, injury or disease. program to assist in determining what and inform the provider and you of the
health care services are covered under appeal process. For more information
For these purposes “generally accepted
the health plan and the extent of such concerning utilization management, you
standards of medical practice” means
coverage. The program assists you in may request a free copy of the criteria we
standards that are based on credible
receiving appropriate health care and use to make specific coverage decisions by
scientific evidence published in peer-
maximizing coverage for those health contacting Member Services.
reviewed medical literature generally
care services. You can avoid receiving
recognized by the relevant medical You may also visit www.aetna.com/
an unexpected bill with a simple call to
community, or otherwise consistent with about/cov_det_policies.html to find our
Member Services. You can find out if your
physician specialty society recommendations Clinical Policy Bulletins and some utilization
preventive care service, diagnostic test or
and the views of physicians practicing in review policies. Doctors or health care
other treatment is a covered benefit —
relevant clinical areas and any other relevant professionals who have questions about
before you receive care — just by calling
factors. your coverage can write or call our Patient
the toll-free number on your ID card. In
Management department. The address
CLIN ICAL POLICY certain cases, we review your request to be
and phone number are on your ID card.
BULLETIN S sure the service or supply is consistent with
established guidelines and is a covered Concurrent Review
Clinical Policy Bulletins (CPBs) describe our Concurrent review is a review conducted
benefit under your plan. We call this
policy determinations of whether certain while a patient is confined on an inpatient
“utilization management review.”
services or supplies are medically necessary basis. The concurrent review process
or experimental or investigational, based assesses the necessity for continued
on a review of currently available clinical stay, level of care, and quality of care for
information. Clinical determinations in members receiving inpatient services.
connection with individual coverage All inpatient services extending beyond
decisions are made on a case-by-case basis the initial certification period require
consistent with applicable policies. concurrent review.
Discharge Planning About Coverage Decisions Certain states mandate external review
Discharge planning may be initiated at Sometimes we receive claims for services of additional benefit or service issues;
any stage of the patient management that may not be covered by your health some may require a filing fee. In addition,
process and begins immediately upon benefits plan. It can be confusing — certain states mandate the use of
identification of post-discharge needs even to your doctors. Our job is to make their own external review process for
during precertification or concurrent coverage decisions based on your specific medical necessity and experimental or
review. The discharge plan may include benefits plan. If a claim is denied, we’ll investigational coverage decisions. These
initiation of a variety of services/benefits send you a letter to let you know. If you state mandates may not apply to self-
that may to be utilized by you upon don’t agree you can file an appeal. To funded plans.
discharge from an inpatient stay file an appeal, follow the directions in
For details about your plan’s appeal
the letter that explains that your claim
Retrospective Record Review process and the availability of an external
was denied. Our appeals decisions will
Retrospective review is a review conducted review process, call the Member Services
be based on your plan provisions and any
after the patient has been discharged from toll-free number on your ID card or visit
state and federal laws or regulations that
the hospital or facility. The purpose of www.aetna.com to print an external
apply to your plan. You can learn more
retrospective review is to analyze potential review request form, or call the Member
about the appeal procedures for your plan
quality and utilization issues, initiate Services toll-free number on your ID card.
from your plan documents.
appropriate follow-up action based on You also may call your state insurance
quality or utilization issues, and review all External Review or health department or consult their
appeals of inpatient concurrent review We established an external review process websites for additional information
decisions for coverage of health care to give you the opportunity of requesting regarding state mandated external review
services. Our effort to manage the services an objective and timely independent procedures.
provided to you includes the retrospective review of certain coverage denials. Once
review of claims submitted for payment, the applicable internal appeal process ME MB E R R I GHT S &
and of medical records submitted for has been exhausted, you may request R E S P O NS I B I L I T I ES
potential quality and utilization concerns. an external review of the decision for You have the right to receive a copy of
the coverage denial if: (a) you would be our Member Rights and Responsibilities
CO MPLA INTS, APPEALS financially responsible for the cost of Statement. This information is available
A ND EXTERNAL RE V IEW services; (b) the amount of the service(s) to you at www.aetna.com/about/
This Complaint Appeal and External is more than $500, and (c) is based MemberRights. You can also obtain a
Review process may not apply if your on lack of medical necessity or on the print copy by contacting Member Services
plan is self-funded. Contact your Benefits experimental or investigational nature of at the number on your ID card.
Administrator if you have any questions. the proposed service or supply. Standards
may vary by state, and several states have ME MB E R S E RV I C E S
Filing a Complaint or Appeal
external review processes that may apply To file a complaint or an appeal, for
We are committed to addressing your
to your plan. additional information regarding
coverage issues, complaints and problems.
If a request meets the requirement for an copayments and other charges, information
If you have a coverage issue or other
external review, an Independent Review regarding benefits, to obtain copies of plan
problem, call Member Services at the toll
Organization (IRO) will assign the case documents, information regarding how
free number on your ID card or e-mail
to an external physician reviewer with to file a claim or for any other question,
us from your secure Aetna Navigator®
appropriate expertise for an independent you can contact Member Services at the
member website. Click on “Contact Us”
decision in the area in question. After all toll-free number on your ID card, or email us
after you log on. You can also contact
necessary information is submitted, an from your secure Aetna Navigator member
Member Services at: www.aetna.com.
external review generally will be decided website at www.aetna.com. Click on
If Member Services is unable to resolve
within 30 calendar days of the request. “Contact Us” after you log on.
your issue to your satisfaction, it will be
forwarded to the appropriate department Expedited reviews are available when your Spanish-speaking hotline –
for handling. physician certifies that a delay in service 1-800-533-6615
would jeopardize your health.
If you are dissatisfied with the outcome of Multilingual hotline – 1-888-982-3862
your initial contact, you may file an appeal. Once the review is complete, the plan (140 languages are available. You must ask
Your appeal will be decided in accordance will abide by the decision of the external for an interpreter.)
with the procedures applicable to your reviewer. The cost for the review will be
plan and applicable state law. Refer to borne by Aetna (except where state law
your plan documents for details regarding requires you to pay a filing fee as part of a
your plan’s appeal procedure. state mandated program).
I N TERPRETER /HE ARING or treatment, the operation of our health To request a printed copy of our Notice
I MPA IRED plans, or other related activities, we use of Privacy Practices, which describes in
When you require assistance from an personal information internally, share it with greater detail our practices concerning use
Aetna representative, call us during regular our affiliates, and disclose it to health care and disclosure of personal information,
business hours at the number on your ID providers (doctors, dentists, pharmacies, please write to:
card. Our representatives can: hospitals and other caregivers), payors Aetna Legal Support Services Department
(health care provider organizations, 151 Farmington Avenue, W121
• Answer benefits questions employers who sponsor self-funded Hartford, CT 06156
• Help you get referrals health plans or who share responsibility
for the payment of benefits, and others You can also visit www.aetna.com
• Find care outside your area and link directly to the Notice of Privacy
who may be financially responsible for
• Advise you on how to file complaints payment for the services or benefits you Practices by selecting the “Privacy Notices”
and appeals receive under your plan), other insurers, link at the bottom of the page.
• Connect you to behavioral health third party administrators, vendors,
consultants, government authorities, and
NO N-DI S C R I MI NAT I O N
services (if included in your plan)
their respective agents. These parties are S TAT E ME NT
• Find specific health information Aetna does not discriminate in providing
required to keep personal information
• Provide information on our Quality confidential as provided by applicable law. access to health care services on the basis
Management program, which evaluates Participating network providers are also of race, disability, religion, sex, sexual
the ongoing quality of our services required to give you access to your medical orientation, health, ethnicity, creed, age or
records within a reasonable amount of national origin. We are required to comply
TDD Member Services – 1-800-628-3323
time after you make a request. with Title VI of the Civil Rights Act of 1964,
(hearing impaired only)
the Age Discrimination Act of 1975, the
Some of the ways in which personal
Americans with Disabilities Act, other laws
Q U A LITY MANAGE MENT information is used include claims payment;
applicable to recipients of federal funds,
P R O G RA MS utilization review and management;
and all other applicable laws and rules.
We have a comprehensive quality medical necessity reviews; coordination
measurement and improvement strategy, of care and benefits; preventive health, US E O F R AC E , E TH N I C I T Y
and do not view it as an isolated, early detection, and disease and case AND L ANGUAGE D ATA
departmental function. Rather, we management; quality assessment and
Aetna members have the option to provide
integrate quality management and improvement activities; auditing and anti-
us with race/ ethnicity and preferred
metrics into all that we do. For details fraud activities; performance measurement
language information. This information is
on our program, goals and our progress and outcomes assessment; health claims
voluntary and confidential. We collect this
on meeting those goals, go to analysis and reporting; health services
information to identify, research, develop,
www.aetna.com/members/ health_ research; data and information systems
implement and/or enhance initiatives
coverage/quality/quality.html. If you management; compliance with legal
to improve health care access, delivery
do not have Internet access and would like and regulatory requirements; formulary
and outcomes for diverse members,
a hard copy of the information referenced management; litigation proceedings;
and otherwise improve services to our
here, please contact Member Services at transfer of policies or contracts to and
members. We will maintain administrative,
the toll-free number on your ID card and from other insurers, HMOs and third party
technical and physical safeguards to protect
request a copy. administrators; underwriting activities; and
information concerning member race,
due diligence activities in connection with
ethnicity and language preference from
P R IVACY NOTICE the purchase or sale of some or all of our
inappropriate access, use or disclosure. This
Aetna considers personal information to be business. We consider these activities key
data will be collected, used or disclosed
confidential and has policies and procedures for the operation of our health plans. To
only in accordance with Aetna policies and
in place to protect it against unlawful use the extent permitted by law, we use and
applicable state and federal requirements. It
and disclosure. By “personal information,” disclose personal information as provided
is not used to determine eligibility, rating or
we mean information that relates to your above without your consent. However, we
claim payment.
physical or mental health or condition, the recognize that you may not want to receive
provision of health care to you, or payment unsolicited marketing materials unrelated For more information, please visit
for the provision of health care to you. to your health benefits. We do not disclose www.aetna.com. If you do not have
Personal information does not include publicly personal information for these marketing Internet access and would like a hard copy
available information or information that purposes unless you consent. We also have of the information referenced here, please
is available or reported in a summarized or policies addressing circumstances in which contact Member Services at the toll-free
aggregate fashion but does not identify you. you are unable to give consent. number on your ID card and request a copy.
When necessary or appropriate for your care
HEALTH INSURANCE
PORTABILITY AND
ACCOUNTABILITY ACT

IF YOU ARE SPEC I AL E NR O L L ME NT who is currently active but would like


RIGHT S a certificate to verify your status. As a
ENROLLED IN A If you are declining enrollment for terminated member, you can request a
yourself or your dependents (including certificate for up to 24 months following
GROUP HEALTH your spouse) because of other health the date of your termination. As an active
insurance or group health plan coverage, member, you can request a certificate at
PL AN, THE any time. To request a Certificate of Prior
you may be able to enroll yourself and
Health Coverage, please contact Member
FOLLOWING your dependents in this plan if you or
Services at the telephone number listed
your dependents lose eligibility for that
on your ID card.
INFORMATION IS other coverage (or if the employer stops
contributing to your or your dependents’
PROVIDED TO NO T I C E R E GAR DI N G
other coverage). However, you must
request enrollment within 31 days after
W O ME N’ S HE ALT H A N D
INFORM YOU OF your or your dependents’ other coverage C ANC E R R I GHT S A C T
ends (or after the employer stops Under this health plan, coverage will be
CERTAIN PROVISIONS contributing to the other coverage). provided to a person who is receiving
benefits for a medically necessary
CONTAINED IN THE In addition, if you have a new dependent
mastectomy and who elects breast
as a result of marriage, birth, adoption or
reconstruction after the mastectomy for:
GROUP HEALTH placement for adoption, you may be able
to enroll yourself and your dependents. (1) reconstruction of the breast on which
PL AN, AND REL ATED However, you must request enrollment a mastectomy has been performed;
within 31 days after marriage, birth, (2) surgery and reconstruction of the
PROCEDURES THAT adoption or placement for adoption. other breast to produce a symmetrical
MAY BE UTILIZED BY To request special enrollment or obtain appearance;
more information, contact your benefits
(3) prostheses; and
YOU IN ACCORDANCE administrator.
(4) treatment of physical complications
WITH FEDER AL L AW. RE QU E S T F O R of all stages of mastectomy, including
CE RT I F I C AT E O F lymphedemas.
CRED I TAB L E C O V E R AGE This coverage will be provided in
If you are a member of an insured plan consultation with the attending physician
sponsor or a member of a self-insured and the patient, and will be subject
plan sponsor who have contracted with to the same annual deductibles and
us to provide Certificates of Prior Health coinsurance provisions that apply for the
Coverage, you have the option to request mastectomy. If you have any questions
a certificate. about our coverage of mastectomies and
This applies to you if you are a reconstructive surgery, please contact the
terminated member, or are a member Member Services number on your ID card.
If you need this material translated into another language, please call Member Services at 1-888-982-3862.
Si usted necesita este documento en otro idioma, por favor llame a Servicios al Miembro al 1-888-982-3862.
Health benefits and health insurance plans are underwritten or administered by Aetna Life Insurance Company. 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. Information subject to change.
The NCQA Accreditation Seal is a recognized symbol of quality. The seal, located on the front cover of your Physician Directory, signifies
that your plan has earned this accreditation for service and clinical quality that meets or exceeds the NCQA’s rigorous requirements for
consumer protection and quality improvement. The number of stars on the seal represents the accreditation level the plan has achieved.
Health care providers who have been duly recognized by the NCQA Recognition Programs are annotated in the Physician Directory.
Providers, in all settings, achieve recognition by submitting data that demonstrates they are providing quality care. The program
constantly assesses key measures that were carefully defined and tested for their relationship to improved care, therefore, NCQA provider
recognition is subject to change. For up-to-date information, please visit our DocFind® directory at www.aetna.com or, if applicable, visit
the NCQA’s new top-level recognition listing at www.ncqa.org/tabid/58/Default.aspx. If you do not have access to the Internet and
would like a printed physician directory, please contact Member Services at the toll-free number shown on your Aetna ID card.
I ALWAYS NEED SOME
INCENTIVE TO GET IN SHAPE.
WHAT CAN YOU OFFER ME?
A fit body is a healthier body. Aetna So get ready to start exercising —
can help you stay in shape. Access the and feeling good.
Aetna FitnessSM discount program and
you’ll receive preferred rates on gym With these savings, it’s a great
memberships as well as discounts on time to join the Fitness Program
at-home weight loss programs, home from Aetna.
fitness options, and one-on-one health
Explore a smarter health plan.
coaching services through GlobalFitTM.
Visit us at www.getaquickquote.com
.
63.44.318.1 (1/11)
E T N A

S
A

R
0
YEA
15
MOR

0
5
E

TH 1
Aetna has been in business for more
than 150 years.
AN
In 2010, for the third year in a row, Aetna
was named the most admired health care
insurance company by Fortune magazine.*

* Fortune magazine, March 22, 2010, March 16, 2009, and March 17, 2008

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 benefits and insurance plans and 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/
dental 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 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. [Aexcel designation is only a guide to choosing a physician. Members should confer
with their existing physicians before making a decision. Designations have the risk of error and should not be the sole basis for selecting a doctor.] Health
information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care profes-
sional. Information is believed to be accurate as of production date, however, it is subject to change.
IN CT, THIS PLAN IS ISSUED ON AN INDIVIDUAL BASIS AND IS REGULATED AS AN INDIVIDUAL HEALTH INSURANCE PLAN.
Policy forms issued in Oklahoma include: Comprehensive PPO-GR-11741 (5/04); Limited-GR-11741-LME (5/04) and Dental-11826 Ed 9/04.
For more information about Aetna plans, refer to www.getaquickquote.com
.
©2010 Aetna Inc.
63.43.300.1 (1/11)

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