Your Benefits Quick Start Guide

Transcription

1 Your Benefits Quick Strt Guide Enroll in the Aetn insurnce plns offered through Sfewy Inc. tody Unexpected stuff hppens to ll of us. Tht s why you need to be redy with insurnce options from Aetn Voluntry Plns. This is your opportunity to sign up for benefits. So tke few minutes to find out bout your options now! Plese note, these plns provide supplementl benefits nd re not substitute for comprehensive medicl insurnce. You hve limited time to enroll. If you were just hired, you hve 45 dys from the dte you re hired to enroll. Aetn Dentl Pln Covers portion of your bill for common dentl procedures. Dentl PPO SAFEWAY INC. GROUP NUMBER: YOUR NAME: FOR MEMBER SERVICES CALL Cut out your temporry member identifiction long the dotted line. These plns do not count s minimum essentil coverge under the ffordble cre ct. These re supplement to helth insurnce nd re not substitute for mjor medicl coverge. Lck of mjor medicl coverge (or other minimum essentil coverge) my result in n dditionl pyment with your txes SGE (05/16) C (11/15)

2 Strt your benefits! How do I enroll? First, red your enrollment informtion. To enroll, visit or cll Follow the instructions on your How to Enroll Guide. Am I eligible to enroll? All prt-time employees nd ll full-time Mrketplce new hire employees in their witing period re eligible to prticipte. If you re n eligible employee, you cn lso enroll your eligible dependents. Your eligible dependents re your lwful spouse or registered domestic prtner nd your children from birth until ge 26, through ny ge if hndicpped nd unble to ern living, or until they cn no longer be leglly declred s dependents. Dependent ge nd sttus requirements my vry by stte. How do I py? Pyment is simple. Premium costs will be deducted from your pycheck. If you miss pyment, you cn py directly nd keep your coverge ctive. There is form in this kit to use when sending in missed premium pyments. When does coverge begin? Coverge is effective on the first dy of the py period following the py period in which deduction occurs. Signing up is esy! First, red your enrollment informtion. Cll Between 8.m. nd 6 p.m., Mondy through Fridy.Or visit If you require lnguge ssistnce, plese cll Member Services t nd n Aetn representtive will connect you with n interpreter. If you re def or hrd of hering, use your TTY nd dil 711 for the Telecommunictions Rely Service. Once connected, plese enter or provide the Aetn telephone number you re clling. Si usted necesit sistenci lingüístic, por fvor llme l Servicios l Miembro , y un representnte de Aetn le conectrá con un intérprete. Si usted es sordo o tiene problems de udición, use su TTY y mrcr 711 pr el Servicio de Retrnsmisión de Telecomunicciones (TRS). Un vez conectdo, por fvor entrr o proporcionr el número de teléfono de Aetn que está llmndo. If you choose Dentl coverge, plese use this temporry member ID until you get your plstic member ID crd. INSURED: The person listed on the crd hs been enrolled in Limited Dentl pln sponsored by the employer. Avilble benefits re subject to exclusions nd limittions. This crd does not gurntee coverge. For verifiction of coverge, filing clim or for questions other thn the discount progrms, contct us t the number printed on the front of this crd or mil us t the ddress below. EMERGENCY: Cll 911 or go to the nerest emergency fcility. Aetn Voluntry Plns P.O. Box Lexington, KY Insurnce plns re underwritten by Aetn Life Insurnce Compny (Aetn). This mteril is for informtion only. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to helth services. Insurnce plns contin exclusions nd limittions. Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. See the limittions nd exclusions document included in this kit for the Aetn insurnce plns offered by your employer. Policy forms issued include: GR-9N, GR-29N Aetn Inc SGE (05/16) C (11/15)

3 Aetn Voluntry Plns Aetn Life Insurnce Compny Missed Premium Pyment Coupon Compny nme Group number Tody s dte (mm/dd/yyyy) Member nme (lst, first, middle initil) Member dytime telephone number lst four of Socil Security Number Pyment will be pplied to the oldest gp in coverge within the lst 45 dys from the postmrk on your miled pyment. To find out wht gps in coverge you my hve, plese cll us toll free t X $ = $ Number of py periods missed Amount of deduction per py period Full premium pyment due Instructions: Mke copy of this pge. Complete the pyment coupon. Cut long the dotted line. Mil coupon with your full mount, mde pyble to Aetn Life Insurnce Compny, to: Missed Premiums P.O. Box Atlnt, GA Wht if I miss pyroll deduction? Ech pyroll deduction pys for coverge for one pyroll period. If you miss pyroll deduction fter your coverge begins, you will not hve coverge during the time tht pyroll deduction would cover, unless you py the full missed premium directly to Aetn Voluntry. Will my insurnce be cnceled if I don t mke up missed premium? Once your coverge hs begun, it will not be cnceled becuse you do not mke up missed premium. However, no clims will be pid for losses or covered expenses tht occur during the period for which premium is unpid. How do I py my missed premium? To py by personl check, cshier s check, or money order, mke pyble to Aetn Life Insurnce Compny nd send with completed copy of the coupon bove to: Missed Premiums, P.O. Box , Atlnt, GA You cn get dditionl pyment coupons by clling If the deduction you missed ws your first deduction, include copy of your Enrollment/Chnge Request form nd How to Enroll guide with your confirmtion number written on it, or your online enrollment confirmtion. Your missed premium pyment will strt your coverge. Cn I pick which missed premiums I wish to py? No. Your missed premium pyment will lwys be pplied to the oldest gp in coverge within the lst 45 dys (from the postmrk on your miled pyment). You cnnot choose to cover lter gp in coverge if you hve n erlier gp within the pst 45 dys from the dte your pyment is postmrked. To find out wht gps in coverge you my hve, plese cll toll free , Mondy through Fridy, 8.m. to 6 p.m. How long do I hve to py missed premium? You my py for gp in coverge tht is up to 45 dys old, from the dte your pyment is postmrked. Plese note, if you hve gp in coverge of more thn 30 dys, your 3 to12 month witing period for dentl services will reset. Cn I py just prt of missed premium? No. You must py the full premium deduction tht ws missed in your pycheck, for ll coverge you hve. We cnnot ccept prtil pyments. If I become ineligible or my employment ends, cn I continue coverge with missed premium pyments? No. If your coverge termintes, you my not continue coverge by pying missed premiums. Insurnce plns re underwritten by Aetn Life Insurnce Compny (Aetn). Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge Aetn Inc D (03/15)

4 Qulity helth plns & benefits Helthier living Finncil well-being Intelligent solutions Be prepred with dentl cre Aetn Dentl Pln Protect your smile tody nd tomorrow If you hd cvity, would you hve the money vilble to tke cre of it? Now you cn be redy with n Aetn Dentl pln. The dentl insurnce pln is ffordble nd gret wy to help you nd your loved ones keep your smiles helthy. The pln provides: Benefits to help you py for checkups, clenings nd common dentl services The flexibility to see ny dentist you like Access to discounted rtes through Aetn s brod network of dentists Group rtes which re typiclly lower thn those you cn find on your own Esy pyroll deduction How the pln works Once the nnul deductible is met, the pln helps py for mny of the most common dentl services up to its stted nnul limit. These include: Preventive services like checkups nd clenings Bsic services like fillings nd orl surgery Mjor services like crowns, bridges, dentures nd root cnls (benefits vry by pln) Witing periods my pply to some services. See your enrollment informtion for detils (03/15)

5 Locte locl preferred Dentl provider by visiting: Exclusions nd limittions The dentl preferred provider orgniztion (PPO) network is not vilble in Albm, Arknss, Idho, Hwii, Louisin, Mississippi, New Mexico or Puerto Rico. To locte preferred provider, cll toll-free Aetn will py benefits only for expenses incurred while this coverge is in force, nd only for the necessry tretment of injury or disese. A service or supply is necessry if it is determined by Aetn to be pproprite for the dignosis, cre or tretment of the disese or injury involved. The pln requires tht deductible is met before benefit is pid except for preventive services. In cse of emergency, cll 911 or your locl emergency hotline; or go directly to n emergency cre fcility. Did you know there s link between dentl helth nd overll helth? Reserch hs shown tht diseses of the teeth nd gums re risk fctors for dibetes, kidney disese, hert disese nd even cncer. So going to the dentist twice yer is bout more thn hving nice smile. 1 Enroll Tody. Follow the instructions provided in your enrollment mterils. A deductible is the mount you must py for eligible expenses before the pln begins to py benefits. This pln does not cover ll helth cre expenses nd hs exclusions nd limittions. Your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. The following chrges re not covered under the dentl pln, nd they will not be recognized towrd stisfction of ny deductible mount: Cosmetic procedures unless needed s result of injury Any procedure, service or supply tht is included s covered medicl expenses under nother group medicl expense benefit pln Prescribed drugs, premediction, nlgesi or generl nesthesi Services provided for ny type of temporomndibulr (TMJ) or relted structures, or myofscil pin Chrges in excess of the Recognized Chrge [Required Stte mndte lnguge] 1 Everydy Helth. Dentl Helth nd Overll Helth. Helthy mouth, helthy body: The link between them my surprise you. Avilble t: Accessed June, Dentl insurnce plns re underwritten nd dministered by Aetn Life Insurnce Compny (Aetn). This mteril is for informtion only. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to dentl services. Dentl insurnce plns contin exclusions nd limittions. Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. Policy forms issued include: GR-9N, GR-29N Aetn Inc (03/15)

6 Sfewy Inc BENEFITS SUMMARY Aetn Voluntry Plns Pln design nd benefits insured nd dministered by Aetn Life Insurnce Compny (Aetn). Unless otherwise indicted, ll benefits nd limittions re per covered person. Inside this Benefits Summry: Dentl Dentl Mximum benefit per coverge yer Deductible per coverge yer Preventive services (includes checkups nd clenings) Bsic services (includes fillings, orl surgery, nd denture, crown nd bridge repir) $500 $50 You re responsible for pying up to 20% of the Recognized Chrges. These services hve no witing period. You re responsible for pying up to 40% of the Recognized Chrges. You must be covered under the dentl pln without interruption for 3 months before the pln begins to py for these services. Mjor services (includes Perio nd Endodontics, crowns, bridges, nd dentures) You re responsible for pying up to 50% of the Recognized Chrges. You must be covered under the dentl pln without interruption for 12 months before the pln begins to py for these services. The percentge of the cost tht you re responsible for pying preferred provider is bsed on Negotited Chrge. A Negotited Chrge is the mximum mount tht preferred provider hs greed to chrge for covered visit, service, or supply. After your pln limits hve been reched, the provider my require tht you py the full chrge rther thn the Negotited Chrge. The percentge of the cost tht you re responsible for pying non-preferred provider is bsed on Recognized Chrge. A Recognized Chrge is the mount tht Aetn recognizes s pyble by the pln for visit, service, or supply. For nonpreferred providers (except inptient nd outptient fcilities nd phrmcies), the Recognized Chrge generlly equls the 80th percentile of wht providers in tht geogrphic re chrge for tht service, bsed on the FAIR Helth RV Benchmrks dtbse from FAIR Helth, Inc. This mens tht 80% of the chrges in the dtbse for geogrphic re re tht mount or less nd 20% re more for tht service or supply. For preferred providers, the Recognized Chrge equls the Negotited Chrge. A non-preferred provider my require tht you py more thn the Recognized Chrge, nd this dditionl mount would be your responsibility. The dentl PPO network is not vilble in Albm, Arknss, Idho, Hwii, Louisin, Montn, Mississippi, New Mexico or Puerto Rico. To locte preferred provider, cll toll-free or visit In Texs, the Preferred Provider Orgniztion (PPO) network is known s the Prticipting Dentl Network (PDN). 05/02/2016 Benefits Summry Pge 1

7 Sfewy Inc Dentl Exclusions: This pln does not cover ll helth cre expenses nd hs exclusions nd limittions. Members should refer to their booklet certificte to determine which helth cre services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. The following chrges re not covered under the dentl pln, nd they will not be recognized towrd stisfction of ny deductible mount. Cosmetic procedures unless needed s result of injury. Any procedure, service or supplies tht re included s covered medicl expenses under nother group medicl expense benefit pln. Prescribed drugs, pre-mediction, nlgesi or generl nesthesi. Services provided for ny type of temporomndibulr (TMJ) or relted structures, or myofscil pin. Chrges in excess of the Recognized Chrge, bsed on the 80th percentile of the FAIR Helth RV Benchmrks. 05/02/2016 Benefits Summry Pge 2

8 Sfewy Inc Questions nd nswers Wht should I do in cse of n emergency? In cse of emergency, cll 911 or your locl emergency hotline, or go directly to n emergency cre fcility. Wht if I don t understnd something I ve red here, or hve more questions? Plese cll us. We wnt you to understnd these benefits before you decide to enroll. You my rech one of our Customer Service representtives Mondy through Fridy, 8.m. to 6 p.m., by clling toll free We re here to nswer questions before nd fter you enroll. Importnt informtion bout your benefits Serch our network for doctors, hospitls nd other helth cre providers Here s how you cn find out if your helth cre provider is in our network. Log in to nd follow the pth to find doctor, or cll us t the toll-free number on your Aetn ID crd. If you would like printed list of doctors, contct Member Services t the toll-free number on your Aetn ID crd. Our online directory is more thn just list of doctors nmes nd ddresses. It lso includes informtion bout where the physicin ttended medicl school, bord certifiction sttus, lnguge spoken nd gender. You cn even get driving directions to the office. If you don t hve Internet ccess, cll Member Services to sk bout this informtion. Complints nd ppels Plese tell us if you re not stisfied with response you received from us or with how we do business. Cll Member Services to file verbl complint or to sk for the ddress to mil written complint. You cn lso e-mil Member Services through the secure member website. If you re not stisfied fter tlking to Member Services representtive, you cn sk us to send your issue to the pproprite deprtment. If you don t gree with denied clim, you cn file n ppel. To file n ppel, follow the directions in the letter or explntion of benefits sttement tht explins tht your clim ws denied. The letter lso tells you wht we need from you nd how soon we will respond. We protect your privcy We consider personl informtion to be privte. Our policies protect your personl informtion from unlwful use. By personl informtion, we men informtion tht cn identify you s person, s well s your finncil nd helth informtion. Personl informtion does not include wht is vilble to the public. For exmple, nyone cn ccess informtion bout wht the pln covers. It lso does not include reports tht do not identify you. When necessry for your cre or tretment, the opertion of our helth plns or other relted ctivities, we use personl informtion within our compny, shre it with our ffilites nd my disclose it to: your doctors, dentists, phrmcies, hospitls nd other cregivers, other insurers, vendors, government deprtments nd third-prty dministrtors (TPAs). We obtin informtion from mny different sources prticulrly you, your employer or benefits pln sponsor if pplicble, other insurers, helth mintennce orgniztions or TPAs, nd helth cre providers. These prties re required to keep your informtion privte s required by lw. Some of the wys in which we my use your informtion include: Pying clims, mking decisions bout wht the pln covers, coordintion of pyments with other insurers, qulity ssessment, ctivities to improve our plns nd udits. We consider these ctivities key for the opertion of our plns. When llowed by lw, we use nd disclose your personl informtion in the wys explined bove without your permission. Our privcy notice includes complete explntion of the wys we use nd disclose your informtion. It lso explins when we need your permission to use or disclose your informtion. We re required to give you ccess to your informtion. If you think there is something wrong or missing in your personl informtion, you cn sk tht it be chnged. We must complete your request within resonble mount of time. If we don t gree with the chnge, you cn file n ppel. If you d like copy of our privcy notice, cll or visit us t 05/02/2016 Benefits Summry Pge 3

9 Sfewy Inc If you require lnguge ssistnce, plese cll Member Services t nd n Aetn representtive will connect you with n interpreter. If you re def or hrd of hering, use your TTY nd dil 711 for the Telecommunictions Rely Service. Once connected, plese enter or provide the Aetn telephone number you re clling. Si usted necesit sistenci lingüístic, por fvor llme l Servicios l Miembro , y un representnte de Aetn le conectrá con un intérprete. Si usted es sordo o tiene problems de udición, use su TTY y mrcr 711 pr el Servicio de Retrnsmisión de Telecomunicciones (TRS). Un vez conectdo, por fvor entrr o proporcionr el número de teléfono de Aetn que está llmndo. This mteril is for informtion only nd is not n offer or invittion to contrct. Insurnce plns contin exclusions nd limittions. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to helth services. Not ll helth services re covered. See pln documents for complete description of benefits, exclusions, limittions nd conditions of coverge. Pln fetures nd vilbility my vry by loction. Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. Finncil Snctions Exclusions Cluse If coverge provided by this policy violtes or will violte ny US economic or trde snctions, the coverge is immeditely considered invlid. For exmple, Aetn compnies cnnot mke pyments or reimburse for helth cre or other clims or services if it violtes finncil snction regultion. This includes snctions relted to blocked person or entity, or country under snction by the United Sttes, unless permitted under vlid written Office of Foreign Assets Control (OFAC) license. For more informtion on OFAC, visit Policy forms issued include GR-9N, GR-29N. 05/02/2016 Benefits Summry Pge 4

10 How to enroll Aetn Voluntry Plns Red the mterils in this enrollment kit nd sk questions. If you or your fmily need to know more, or don t completely understnd something, plese cll us toll free t or visit We re here to nswer questions before nd fter you enroll. Fill out your Enrollment/Chnge Request form. Then follow the instructions below to enroll, online or by telephone, using the informtion you wrote on the form. You do not need to give this form to your employer. If you re currently enrolled, nd do not wish to mke chnges, you do not need to do nything to continue your existing coverge. To enroll online: A Go to B Click on Log In, which will tke you to the ccount ccess pge. C Select Log In from the menu. Enter the user nme nd pssword. User nme: Pssword: 0532 D Choose Enrollment from the pnel on the left. Then follow the online instructions. E When complete, print copy of the Confirmtion pge for your records. Your Confirmtion Number is proof of successful enrollment. Do not hnd nything in to your employer. To enroll by telephone: A Below is list of product offered through your employer. For ech type of coverge, circle level of coverge you wnt. Dentl Dentl PPO network is not vilble in AL, AR, ID, HI, LA, MT, MS, NM or PR. Yourself only Yourself plus spouse Yourself nd fmily B Cll to enroll. Follow the instructions you her on the phone to spek to live representtive for enrollment. To spek with live Customer Service Representtive, cll Mondy through Fridy, 8.m. to 6 p.m. If enrolling outside of these times, plese cll gin lter to give your informtion. C If you enroll your dependent(s) or choose coverge, remember to give your dependent informtion to Customer Service representtive. D Keep your completed Enrollment/Chnge Request form nd this enrollment guide for your records. Do not hnd nything in to your employer C SfewyInc (05/16)

11 How to mke chnges You my mke chnges to your enrollment t ny time before the end of your enrollment period by following the enrollment instructions on the front of this guide. If your enrollment period is over, you my need Qulifying Life Event (QLE) to mke chnges. You must mke your chnges within 31 dys of the QLE. You will need QLE to dd or increse coverge. You my drop or decrese ny coverge t ny time without QLE. For list of QLEs, plese see the bck of your Enrollment/Chnge Request form, sk your employer or cll Mke chnges by filling out n Enrollment/Chnge Request form. Then follow the instructions below to mke chnges, online or by telephone, using the informtion you wrote on the form. You do not need to give this form to your employer. To mke chnges online: If your enrollment period is over, you my need Qulifying Life Event (QLE) to mke chnges. You must mke your chnges within 31 dys of the QLE. A Go to B Click on Log In, which will tke you to the ccount ccess pge. C Select Log In from the menu. Enter the user nme nd pssword. User nme: Pssword: 0532 D Choose Enrollment from the pnel on the left. Then follow the online instructions to mke chnges. E After you hve mde your chnges, print copy of the Confirmtion pge for your records. Your Confirmtion Number is proof tht your chnges re successful. Do not hnd nything in to your employer. To mke chnges by telephone: If your enrollment period is over, you my need Qulifying Life Event (QLE) to mke chnges. You must mke your chnges within 31 dys of the QLE. You will be sked for your Socil Security number to mke chnges. A Cll to enroll. Follow the instructions you her on the phone to spek to live representtive for enrollment. To spek with live Customer Service Representtive, cll Mondy through Fridy, 8.m. to 6 p.m. If enrolling outside of these times, plese cll gin lter to give your informtion. B Keep your completed Enrollment/Chnge Request form nd this enrollment guide for your records. Do not hnd nything in to your employer. Insurnce plns re underwritten by Aetn Life Insurnce Compny (Aetn). Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. Policy forms issued include GR-9N, GR-29N C SfewyInc (05/16)

12 Aetn Voluntry Plns Enrollment/Chnge Request Insurnce plns re underwritten by Aetn Life Insurnce Compny (Aetn). Sfewy Inc TO COMPLY WITH CALIFORNIA LAW, THE TERM "SPOUSE" SHALL BE CONSTRUED TO INCLUDE A DOMESTIC PARTNER. Instructions: Red nd fill out the Enrollment/Chnge Request (ll pges). IF YOU ARE NOT CHANGING YOUR EXISTING COVERAGE, YOU DO NOT NEED TO COMPLETE THIS ENROLLMENT/CHANGE REQUEST. INFORMATION ABOUT YOU Complete ll informtion. Print your nme (first, middle initil, lst) Socil Security Number Dte of birth (MM/DD/YYYY) Home ddress Aprtment number City Stte Zip code Home phone Work phone Emil ddress ( ) ( ) ACTION YOU WANT TO TAKE Check the box next to the ction you wnt to tke. I m not currently enrolled nd I wnt to I m currently enrolled nd I wnt to Your pyroll deductions will be tken fter txes re tken. Sex Mle Femle Primry lnguge spoken (Idiom principl) Enroll in the coverge choices selected below. Decline this opportunity to prticipte. Mke chnges to my current coverge choices (dd, increse, drop, decrese) s selected below. All of my other coverge choices will remin the sme s previously elected. (If outside of n open enrollment, see Mking Chnges Outside of n Open Enrollment. ) Updte my personl nd/or my dependent informtion. Drop ll of my current coverge choices. YOUR COVERAGE CHOICES Check( ) the box for the level of coverge you wnt. Coverge type Coverge level Weekly cost Dentl No Dentl Yourself only... $ 4.67 Yourself plus one... $ 9.35 Yourself nd fmily... $ EMPLOYER GROUP INFORMATION This section is to be completed by your employer. Employee ID Hire dte (MM/DD/YYYY) Py type Totl deduction ($) Effective dte (MM/DD/YYYY) Loction or site code Authorized signture Title Tody s dte (MM/DD/YYYY) CA This Enrollment/Chnge Request is not proof of coverge ECRE AFBP_DE 05/03/2016

13 INFORMATION ABOUT YOU Repet your nme nd Socil Security number here. Print your nme (first, middle initil, lst) Socil Security Number INFORMATION ABOUT YOUR DEPENDENTS List the dependents for whom you re dding/chnging/removing coverge. If you hve more dependents, write down their informtion on seprte sheet nd ttch it to this Enrollment/Chnge Request. Add Chnge Print dependent s nme (first, middle initil, lst) Socil Security Number Remove Sex Dte of birth Mle / Femle Reltionship: Spouse Registered domestic prtner Child Other (Specify): Address (if different thn yours) City Stte Zip code Add Chnge Remove Add Chnge Remove Print dependent s nme (first, middle initil, lst) Socil Security Number Sex Dte of birth Mle / Femle Reltionship: Spouse Registered domestic prtner Child Other (Specify): Address (if different thn yours) City Stte Zip code Print dependent s nme (first, middle initil, lst) Socil Security Number Sex Dte of birth Mle / Femle Reltionship: Spouse Registered domestic prtner Child Other (Specify): Address (if different thn yours) City Stte Zip code MAKING CHANGES OUTSIDE OF AN OPEN ENROLLMENT Plese red below to see if you re ble to mke chnges to your coverge. You cn dd to or increse your coverge during the pln yer only if you hve Loss of Other Coverge (LOC): Qulifying Life Event (QLE). If your deductions re tken fter txes, you my drop or Divorce, legl seprtion or deth decrese coverge t ny time. QLEs fll under one of these two ctegories: Termintion of employment of dependent Loss of Other Coverge (LOC): If you previously declined helth coverge becuse you or Reduction of dependent s hours your dependents were lredy covered under nother helth pln nd you or your Termintion of your or your dependents COBRA dependents hve lost tht other coverge, you my be ble to enroll yourself nd your rights dependents. If you hd recent LOC, go to the list on the right nd check the box next to Loss of employer s contribution to spouse s or your LOC nd supply the dte of the LOC. registered domestic prtner s coverge Fmily Sttus Chnge (FSC): Whether you re currently enrolled or previously declined Dependent child losing eligibility s dependent coverge, you my be ble to dd or increse coverge when you experience certin FSC Other loss of coverge events. If you hd recent FSC, go to the list on the right nd check the box next to your Fmily Sttus Chnge (FSC): FSC nd supply the dte of the FSC. Divorce, legl seprtion or deth Mrrige Birth or doption of dependent Other Dte of LOC or FSC (mm/dd/yyyy) YOUR AUTHORIZATION You must sign nd dte this Enrollment/Chnge Request for ll new enrollments or coverge chnges. I represent tht ll informtion supplied in this Enrollment/Chnge Request is true nd complete to the best of my knowledge nd/or belief. I hve red nd gree to the Conditions of Enrollment on the lst pge of this Enrollment/Chnge Request. Your signture Tody s dte (MM/DD/YYYY) CA This Enrollment/Chnge Request is not proof of coverge ECRE AFBP_DE 05/03/2016

14 CONDITIONS OF ENROLLMENT Applicnt cknowledgments nd greements NOTICE: Cliforni lw prohibits n HIV test from being required or used by helth insurnce compnies s condition of obtining helth insurnce coverge. On behlf of myself nd the dependents listed on this Enrollment/Chnge Request, I gree to or with the following: 1. I cknowledge tht by enrolling in n Aetn pln coverge is underwritten nd dministered by Aetn Life Insurnce Compny (Aetn) 151 Frmington Avenue, Hrtford, CT I uthorize deductions from my ernings for ny contributions required for coverge nd I gree to mke ny necessry pyments s required for coverge. 3. I understnd nd gree tht this Enrollment/Chnge Request my be trnsmitted to Aetn or its gent by my employer or its gent. I uthorize ny physicin, other helthcre professionl, hospitl or ny other helthcre orgniztion ("Providers") to give Aetn or its gent informtion concerning the medicl history, services or tretment provided to nyone listed on this Enrollment/Chnge Request, including those involving mentl helth, substnce buse nd AIDS. I further uthorize Aetn to use such informtion nd to disclose such informtion to ffilites, providers, pyors, other insurers, third prty dministrtors, vendors, consultnts nd governmentl uthorities with jurisdiction when necessry for my cre or tretment, pyment for services, the opertion of my helth pln, or to conduct relted ctivities. I hve discussed the terms of this uthoriztion with my spouse or domestic prtner nd competent dult dependents nd I hve obtined their consent to those terms. I understnd tht this uthoriztion is provided under stte lw nd tht it is not n "uthoriztion" within the mening of the federl Helth Insurnce Portbility nd Accountbility Act. This uthoriztion will remin vlid for the term of the coverge nd so long therefter s llowed by lw. I understnd tht I m entitled to receive copy of this uthoriztion upon request nd tht photocopy is s vlid s the originl. 4. The pln documents will determine the rights nd responsibilities of covered person(s) nd will govern in the event they conflict with ny benefits comprison, summry or other description of the pln. 5. I understnd nd gree tht ll prticipting providers nd vendors re independent contrctors nd re neither gents nor employees of Aetn. Aetn Rx Home Delivery, LLC nd Aetn Specilty Phrmcy, LLC, wholly owned subsidiries of Aetn Inc., re prticipting providers nd independent contrctors of Aetn, nd re neither gents nor employees of Aetn. The vilbility of ny prticulr provider cnnot be gurnteed nd provider network composition is subject to chnge. Notice of the chnge shll be provided in ccordnce with pplicble stte lw. Aetn does not provide helth or dentl cre services nd, therefore, cnnot gurntee ny results or outcome. Some benefits re subject to limittions or mximums. 6. Attention Cliforni Residents: For your protection Cliforni lw requires notice of the following to pper on this form: The flsity of ny sttement in this Enrollment/Chnge Request shll not br the right to recovery under the policy unless such flse sttement ws mde with ctul intent to deceive or unless it mterilly ffected either the cceptnce of the risk or the hzrd ssumed by Aetn. Attention Pennsylvni Residents: Any person who knowingly nd with intent to defrud ny insurnce compny or other person files n ppliction for insurnce or sttement of clim contining ny mterilly flse informtion or concels, for the purpose of misleding, informtion concerning ny fct mteril thereto commits frudulent insurnce ct, which is crime nd subjects such person to criminl nd civil penlties. Attention Rhode Islnd Residents: Any person who knowingly presents flse or frudulent clim for pyment of loss or benefit or knowingly presents flse informtion in n ppliction for insurnce is guilty of crime nd my be subject to fines nd confinement in prison CA This Enrollment/Chnge Request is not proof of coverge ECRE AFBP_DE 05/03/2016

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