GEORGIA PLAN GUIDE. Aetna Avenue Your Destination for Small Business Solutions. Plans effective OCTOBER 1, 2010

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1 Aetna Avenue Your Destination for Small Business Solutions GEORGIA PLAN GUIDE Plans effective OCTOBER 1, 2010 For businesses with 2-99 eligible employees GA C (8/11)

2 Georgia plan GUIDE Health care is a journey Aetna Avenue is the way In this guide: 2 Small business commitment 3 Benefits for every stage of life 4 Provider network 5 Medical overview 11 Medical plan options 20 Dental overview 22 Dental plan options 30 Life & disability overview 32 Life plan options 33 Life & disability plan options 34 Underwriting guidelines 38 Product specifications 44 Limitations and exclusions 48 Group enrollment checklist As a small business owner, providing value to your customers and growing your business are your top priorities. Yet, today health care is a business issue for every entrepreneur. Small businesses need health benefits and insurance plans that fit their workplace. Aetna Avenue provides employers with a choice of insurance benefits solutions. We know that choice, ease and reputation are as valuable to employers as they are to employees. Aetna offers a variety of plans for small business from medical plans, to dental, life and disability plans. Health/Dental benefits and health/dental insurance plans are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).

3 CHOICE For business owners and employees At Aetna, we provide employers a choice of health benefits and insurance plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. Employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care. Medical plans supporting members on their health care journey 100% plans Traditional plans HSA-compatible plans Consumer-directed health plans Dental, life and disability plans providing valuable protection DMO PPO PPO Max Freedom-of-Choice plan design Preventive Basic term life insurance Packaged life and disability plans Ease Allowing you to focus on your business Employers want to focus on their customers and growing their business not the health insurance benefits program. Aetna makes sure that our plan designs are easy to set-up, administer, use and provide support to ensure your success. Administration making it work for your business Aetna s plan designs automatically process health claim reimbursements, provide a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Secure and online, ebusiness makes managing health benefits easy and eliminates time-consuming, expensive paper-based processes. Ready on day-one making it work for your employees Once employees are members of the Aetna health benefits and health insurance plans, they ll have access to our various tools and resources to help them use the plans effectively from the start. Aetna Navigator our online resource for employers, members and providers Look up rates for providers, facilities and hospitals for common services and treatment Track medical claims online Discount programs for eye, dental and other health care Personal Health Record providing a complete picture of health Simple Steps To A Healthier Life, an online health and wellness program Temporary ID cards available for members to print as needed Reputation In business it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it. Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 1

4 Georgia plan GUIDE Aetna Avenue s commitment to small business employers We know that small business owners health insurance benefits needs are often different than a larger employer. Aetna Avenue focuses on employers with 2-99 employees and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. Aetna s market map Guiding your small business health care journey Aetna s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee need in order to narrow the field of plan design choices. Basic benefits for your employees Limiting the expense to your business Allowing employees to buy-up and share more of the cost You might be a Basic buyer These plans fit Simply Savings plans (1942, 1943, 1944, 1945) Employee responsibility These plans fit Do you value Consumerism s ability to make a difference Tools and resources to support consumerism Innovative plan design You might be a Value seeker HSA-compatible plans (1931, 1932, 1935) Simply Savings (1945) Traditional benefits plans These plans fit Limiting the financial impact on employees You might be a Traditionalist Traditional plans (1902, 1903, 1904, 1905, 1999) 100% plans (1912, 1913, 1914) 2

5 Young Singles Consumer-directed health plans HSA-compatible plans Young Families Traditional plans 100% plans Established FAMILIES Consumer-directed health plans Traditional plans 100% plans Empty Nesters Consumer-directed health plans HSA-compatible plans Health insurance benefits for every stage of life Young singles Includes singles and couples without children Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since they re probably on a budget, they might want an affordable policy with lower monthly payments and modest out-of-pocket costs that also provides for quality preventive care, prescription drug coverage and financial protection to help safeguard their assets. Young families Includes married couples and single parents with young children and teens Children tend to get sick more than adults which means employees and their pediatricians get to know each other quite well. It also means they re probably looking for health coverage with lower fees for office visits, lower monthly payments and caps on their out-of-pocket expenses. And, of course, they can benefit from quality preventive care for the entire family. Established families Includes married couples and single parents with teens and college-aged children As the children get older, the entire family s needs change. Time management is important for active parents and children. Teenagers still need checkups and care for injuries and illness, while parents need to start thinking about their own needs, like plan designs that cover preventive care and screenings and promote a healthy lifestyle. And college brings financial concerns to the forefront, as well as the need for a national network. Empty nesters Includes men and women age 55 and over with no children at home The kids are leaving home. It s a wistful time, but also an exciting one. What are the plans? Travel? Leisure? Reassessing health coverage needs? These employees are probably looking for a policy that combines financial security with quality coverage for prescriptions, hospital inpatient/outpatient services and emergency care. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 3

6 Georgia plan GUIDE GEORGIA Provider Network* County HMO/POS MC Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur Dekalb Dodge Dooly Dougherty Douglas Early Echols Edgefield Effingham Elbert Emanuel County HMO/POS MC Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Harbersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Montgomery Morgan Murray Muscogee Newton County HMO/POS MC Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth *Network subject to change. 4

7 Aetna Avenue Medical Overview Product Name Aetna Open Access HMO (HMO OA) Aetna Open Access Point of Service (POS OA) Aetna Open Access Managed Choice (MC OA) Traditional Choice (Indemnity) Product Description A Health Maintenance Organization (HMO) uses a network of participating providers. Each family member may select a primary care physician (PCP) participating in our network to provide routine and preventive care and can help coordinate the member s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care. Aetna Choice POS (CPOS) is a two-tiered product that allows members to access care in or out of network. Members have lower out-of-pocket costs when they use the in-network tier of the plan. Member cost sharing increases if members decide to go out of network. Members may go to their PCP or directly to a participating specialist without a referral. It is their choice, each time they seek care. Managed Choice members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher outof-pocket costs. This indemnity plan option is available for employees who live outside the plan s network service area. Members coordinate their own health care and may access any recognized provider for covered services without a referral. PCP Required Referrals Required Network No No HMO (Open Access)/Open Access Aetna Health Network Only SM No No Aetna Choice POS (Open Access)/ Open Access Aetna Health Network Option No No Managed Choice POS (Open Access) No No N/A MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 5

8 Georgia plan GUIDE What is Consumer Flex Choice? Consumer Flex Choice makes it possible for a Small Group Employer to tailor his benefits to better meet the needs of his employees. Consumer Flex Choice allows a Small Group Employer to offer to his employees as many medical plan designs as they would like (using the current portfolio). This means an employer is not limited to offering one, two or even three plan options, but can offer a variety of plan designs to the employees in order to meet their specific health care needs. What are the advantages of Consumer Flex Choice? Employers can manage costs. Employer contribution is based on the least expensive plan in the portfolio, regardless of the plans selected or how many plans are offered. Employees can manage choice. Employees can select the benefit plan that meets their individual needs. Most employers have employees and their families who want different things from their medical plans. For instance if an employer has employees who fit the Basic Buyer profile, they may want a medical plan where they share in more of the cost, but employees who are value seekers may want a plan with more investment options such as an HSA compatible plan. Still other employees may prefer a more traditional plan with fixed costs. With Consumer Flex Choice, employers can manage their costs and provide flexibility in choice for their employees. Easy administration. Employer contribution: 50% of the Employee Only Cost of the lowest cost plan in the portfolio (even if the employer does not select that plan). (If the Point of Service is not available, contributions will be based upon the Open Access Managed Choice Employee Only cost). Standard participation underwriting guidelines apply: For non-contributory plans, 100% participation is required, excluding valid waivers. For contributory plans, 75% of eligible employees, excluding valid waivers. At least one employee must be enrolled in each plan offered. 6

9 What is ValuePick? ValuePick* is the Aetna suite of plans designed specifically for small businesses. ValuePick offers reduced minimum participation and employer contribution requirements. ValuePick offers the following advantages: Lower participation and contribution requirements Value plans have lower participation and contribution requirements, except when offered with a non-value plan.** Greater employee choice Employers can offer up to three of the Value plans. Flexibility and affordability By choosing a Value plan, employers are now able to offer benefits to help meet the needs of their employees. Total freedom Aetna is committed to providing solutions to help meet the needs of small businesses. Employers can now offer quality coverage at affordable prices. Easy administration Setting up this program is simple: 1. The employer chooses up to three of the Value plans to offer on the Employer Application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. ValuePick Target audience Small businesses Plan choices Up to 3 of the 4 ValuePick plans Minimum participation 4 or more enrolled employees Employer contribution 25% of the employee premium or $50 per employee Employee participation 50% Contact your local Aetna representative for specific ValuePick plan information. *Available with four or more enrolled employees. ** If an employer chooses a ValuePick plan to offer with a non-value plan, the standard participation and contribution requirements on the non-value plan will apply to both plans offered. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 7

10 Georgia plan GUIDE Health Savings Account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible highdeductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. Aetna highdeductible plans (HSA-compatible) The Aetna insurance options that are compatible with a Health Savings Account (HSA) provide employers and their qualified employees with an affordable tax-advantaged solution that allows them to better manage their qualified medical and dental expenses. Employees can build a savings fund to assist in covering their future medical and dental expenses. HSA accounts can be funded by the employer or employee and are portable. Fund contributions may be taxdeductible (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. 8

11 You own your HSA Contribute tax free HSA Account You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free MEMBER S HSA Plan Today Use for qualified expenses with tax free dollars Future Plan for future and retiree health-related costs High-deductible health plan Eligible in-network preventive care services will not be subject to the deductible You pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 9

12 Georgia plan GUIDE Administrative fees FEE DESCRIPTION FEE HSA Initial Set-Up $0 Monthly Fees $0 POP* Initial Set-Up** $175 Renewal $100 HRA and FSA*** Initial Set-Up* 2-25 Employees $ Employees $ Employees $550 Renewal Fee 2-25 Employees $ Employees $ Employees $325 Monthly Fees $5.25 per participant Additional Set-Up Fee $150 for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation Fee for stacked participants $10.25 per participant Minimum Fees 0-25 Employees $25 per month minimum Employees $50 per month minimum TRA Annual Fee $350 Transit Monthly Fees $4.25 per participant Parking Monthly Fees $3.15 per participant COBRA Employees: Annual Fee $100 Per employee per month $ Employees: Annual Fee $175 Per employee per month $1.02 Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher out-of-pocket health care expenses. Aetna s consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs. COBR A administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to save them time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium Only Plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. Flexible Savings Account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health Care Spending Accounts allow employees to set aside pretax dollars to pay for outof-pocket expenses as defined by the IRS. Dependent Care Spending Accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit Reimbursement Account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. * First year POP fees waived with the purchase of medical with 5-plus enrolled employees. ** Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $75 fee. Non-discrimination testing only available for FSA and POP products. *** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. No initial notices will be provided. If initial notices are requested by the plan sponsor, the cost is $1.50 per notice. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 10

13 Traditional Deductible & Coinsurance Plans GEORGIA (2-99 Employees) Plan or Calendar Year Calendar Calendar Calendar Deductible Type Embedded Embedded Embedded Lifetime Maximum Unlimited Unlimited Unlimited IN NETWORK SERVICES Coinsurance 80% 80% 80% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) See page 17 for endnotes. $500/$1,500 $1,000/$3,000 $1,500/$4,500 Annual Out-of-Pocket (OOP): Individual/Family $2,500/$7,500 $3,000/$9,000 $3,000/$9,000 Wellness On US SM Preventive Care, including Adult Physicals, $0, ded waived $0, ded waived $0, ded waived Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well-Child Care (Age/Frequency schedules apply, includes $0, ded waived $0, ded waived $0, ded waived coverage for immunizations) Physician Services Primary Care Physician Office visit $25, ded waived $30, ded waived $30, ded waived Specialist Office Visit $40, ded waived $50, ded waived $50, ded waived Outpatient Mental Health* $40, ded waived $50, ded waived $50, ded waived Inpatient Services Hospital Inpatient 80%, ded applies 80%, ded applies 80%, ded applies Mental Health Inpatient 80%, ded applies 80%, ded applies 80%, ded applies Outpatient/Other Services Diagnostic Lab $25, ded waived $30, ded waived $30, ded waived Diagnostic X-ray $60, ded waived $75, ded waived $75, ded waived Diagnostic Complex Imaging $300, ded waived 80%, ded waived 80%, ded waived (CAT, MRI, MRA/MRS and PET scans) Outpatient Surgery 80%, ded applies 80%, ded applies 80%, ded applies Emergency Room $150, ded waived $150, ded waived $200, ded waived (Copay waived if admitted) Urgent Care $75, ded waived $75, ded waived $75, ded waived Ambulance (emergency transport) 80%, ded applies 80%, ded applies 80%, ded applies Outpatient Rehabilitative Therapy $40, ded waived $50, ded waived $50, ded waived (30 visits per year) Durable Medical Equipment 80%, ded applies 80%, ded applies 80%, ded applies ($5000 maximum per year) Chiropractic Services $40, ded waived $50, ded waived $50, ded waived (20 visits per year) PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) available at 2.5X copay for up to a 90-day supply $15/$45/$60 $15/$45/$60 $15/$45/$60 Out-of-Network (OON) Services (OON) Services (POS/MC/PPO/Ind only-oon services do NOT apply to HMO plans) Coinsurance 60% 60% 60% Annual Deductible: Individual/Family $1,500/$4,500 $2,000/$6,000 $2,000/$6,000 (*deductible applies to OOP) Annual Out-of-Pocket (OOP): Individual/Family $4,000/$12,000 $6,000/$18,000 $6,000/$18,000 Emergency Room Paid as In-Network Paid as In-Network Paid as In-Network Ambulance (emergency transport) All other Medical Services 60%, ded applies 60%, ded applies 60%, ded applies Retail Pharmacy (Note: OON Pharmacy is not a covered Not Covered $15/$45/$60 $15/$45/$60 benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) HMO Available X POS Available X X X MC Available X X MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 11

14 Georgia plan GUIDE TRADITIONAL DEDUCTIBLE & COINSURANCE Plans GEORGIA (2-99 Employees) Plan or Calendar Year Calendar Calendar Deductible Type Embedded Embedded Lifetime Maximum Unlimited Unlimited IN NETWORK SERVICES Coinsurance 70% 80% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) $2,000/$6,000 $1,500/$4,500 Annual Out-of-Pocket (OOP): Individual/Family $2,000/$6,000 $4,000/$12,000 Wellness On US SM Preventive Care, including Adult Physicals, $0, ded waived $0, ded waived Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well-Child Care (Age/Frequency schedules apply, includes $0, ded waived $0, ded waived coverage for immunizations) Physician Services Primary Care Physician Office visit $40, ded waived $30, ded waived Specialist Office Visit $60, ded waived $60, ded waived Outpatient Mental Health * $60, ded waived $60, ded waived Inpatient Services Hospital Inpatient 70%, ded applies 80%, ded applies Mental Health Inpatient 70%, ded applies 80%, ded applies Outpatient/Other Services Diagnostic Lab $40, ded waived $30, ded waived Diagnostic X-ray $100, ded waived $75, ded waived Diagnostic Complex Imaging 70%, ded applies 80%, ded applies (CAT, MRI, MRA/MRS and PET scans) Outpatient Surgery 70%, ded applies 80%, ded applies Emergency Room $200, ded waived $250, ded waived (Copay waived if admitted) Urgent Care $75, ded waived $75, ded waived Ambulance (emergency transport) 70%, ded applies 80%, ded applies Outpatient Rehabilitative Therapy $60, ded waived $60, ded waived (30 visits per year) Durable Medical Equipment 70%, ded applies 80%, ded applies ($5000 maximum per year) Chiropractic Services $60, ded waived $60, ded waived (20 visits per year) PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) available at 2.5X copay for up to a 90-day supply $15/$45/$60 $15/$45/$70 Out-of-Network (OON) Services (OON) Services (POS/MC/PPO/Ind only-oon services do NOT apply to HMO plans) Coinsurance 50% + Out-of-Network Benefits do not apply to plans limited Annual Deductible: Individual/Family $4,000/$12,000 to HMO option only (*deductible applies to OOP) Annual Out-of-Pocket (OOP): Individual/Family $8,000/$24,000 Emergency Room Paid as In-Network Ambulance (emergency transport) All other Medical Services 50%, ded applies + Retail Pharmacy (Note: OON Pharmacy is not a covered $15/$45/$60 benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) HMO Available X POS Available MC Available X X See page 17 for endnotes. 12

15 100% Plans GEORGIA (2-99 Employees) Plan or Calendar Year Calendar Calendar Calendar Deductible Type Embedded Embedded Embedded Lifetime Maximum Unlimited Unlimited Unlimited IN NETWORK SERVICES Coinsurance 100% 100% 100% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) $1,000/$3,000 * $1,500/$4,500 * $2,500/$7,500 * Annual Out-of-Pocket (OOP): Individual/Family $1,000/$3,000 $1,500/$4,500 $2,500/$7,500 Wellness On US SM Preventive Care, including Adult Physicals, $0, ded waived $0, ded waived $0, ded waived Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well-Child Care (Age/Frequency schedules apply, includes $0, ded waived $0, ded waived $0, ded waived coverage for immunizations) Physician Services Primary Care Physician Office visit $20, ded waived $30, ded waived $40, ded waived Specialist Office Visit $40, ded waived $50, ded waived $60, ded waived Outpatient Mental Health * $40, ded waived $50, ded waived $60, ded waived Inpatient Services Hospital Inpatient 100%, ded applies 100%, ded applies 100%, ded applies Mental Health Inpatient 100%, ded applies 100%, ded applies 100%, ded applies Outpatient/Other Services Diagnostic Lab $20, ded waived $30, ded waived $40, ded waived Diagnostic X-ray $60, ded waived $75, ded waived $100, ded waived Diagnostic Complex Imaging 100%, ded applies 100%, ded applies 100%, ded applies (CAT, MRI, MRA/MRS and PET scans) Outpatient Surgery 100%, ded applies 100%, ded applies 100%, ded applies Emergency Room $200, ded waived $200, ded waived $250, ded waived (Copay waived if admitted) Urgent Care $75, ded waived $75, ded waived $75, ded waived Ambulance (emergency transport) 100%, ded applies 100%, ded applies 100%, ded applies Outpatient Rehabilitative Therapy $40, ded waived $50, ded waived $60, ded waived (30 visits per year) Durable Medical Equipment 100%, ded applies 100%, ded applies 100%, ded applies ($5000 maximum per year) Chiropractic Services $40, ded waived $50, ded waived $60, ded waived (20 visits per year) PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) available at 2.5X copay for up to a 90-day supply $15/$35/$50 $15/$45/$60 $15/$45/$60 Out-of-Network (OON) Services (OON) Services (POS/MC/PPO/Ind only-oon services do NOT apply to HMO plans) Coinsurance 70% 70% 70% Annual Deductible: Individual/Family $3,000/$9,000 $4,000/$12,000 $4,000/$12,000 (*deductible applies to OOP) Annual Out-of-Pocket (OOP): Individual/Family $6,000/$18,000 $10,000/$30,000 $10,000/$30,000 Emergency Room Paid as In-Network Paid as In-Network Paid as In-Network Ambulance (emergency transport) All other Medical Services 70%, ded applies 70%, ded applies 70%, ded applies Retail Pharmacy (Note: OON Pharmacy is not a covered Not Covered $15/$45/$60 $15/$45/$60 benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) HMO Available X POS Available X X X MC Available X X See page 17 for endnotes. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 13

16 Georgia plan GUIDE HSA Compatible Plans GEORGIA (2-99 Employees) Plan or Calendar Year Calendar Calendar Calendar Deductible Type Non-Embedded Non-Embedded Non-Embedded Lifetime Maximum Unlimited Unlimited Unlimited IN NETWORK SERVICES Coinsurance 90% 80% 80% Annual Deductible: Individual/Family $2,000/$4,000 * $3,000/$6,000 * $2,500/$5,000 * (* indicates deductible applies to OOP) Annual Out-of-Pocket (OOP): Individual/Family $3,000/$6,000 $4,000/$8,000 $5,000/$10,000 Wellness On US SM Preventive Care, including Adult Physicals, $0, ded waived $0, ded waived $0, ded waived Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well-Child Care (Age/Frequency schedules apply, includes $0, ded waived $0, ded waived $0, ded waived coverage for immunizations) Physician Services Primary Care Physician Office visit 90%, ded applies 80%, ded applies 80%, ded applies Specialist Office Visit 90%, ded applies 80%, ded applies 80%, ded applies Outpatient Mental Health * 90%, ded applies 80%, ded applies 80%, ded applies Inpatient Services Hospital Inpatient 90%, ded applies 80%, ded applies 80%, ded applies Mental Health Inpatient 90%, ded applies 80%, ded applies 80%, ded applies Outpatient/Other Services Diagnostic Lab 90%, ded applies 80%, ded applies 80%, ded applies Diagnostic X-ray 90%, ded applies 80%, ded applies 80%, ded applies Diagnostic Complex Imaging 90%, ded applies 80%, ded applies 80%, ded applies (CAT, MRI, MRA/MRS and PET scans) Outpatient Surgery 90%, ded applies 80%, ded applies 80%, ded applies Emergency Room 90%, ded applies 80%, ded applies 80%, ded applies (Copay waived if admitted) Urgent Care 90%, ded applies 80%, ded applies 80%, ded applies Ambulance (emergency transport) 90%, ded applies 80%, ded applies 80%, ded applies Outpatient Rehabilitative Therapy 90%, ded applies 80%, ded applies 80%, ded applies (30 visits per year) Durable Medical Equipment 90%, ded applies 80%, ded applies 80%, ded applies ($5000 maximum per year) Chiropractic Services 90%, ded applies 80%, ded applies 80%, ded applies (20 visits per year) PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) available at 2.5X copay for up to a 90-day supply $15/$45/$60, medical deductible applies $15/$45/$60, medical deductible applies $15/$45/$60, medical deductible applies Out-of-Network (OON) Services (OON) Services (POS/MC/PPO/Ind only-oon services do NOT apply to HMO plans) Coinsurance 50% 50% 60% Annual Deductible: Individual/Family $3,000/$6,000 $4,000/$8,000 $3,500/$7,000 (*deductible applies to OOP) Annual Out-of-Pocket (OOP): Individual/Family $6,000/$12,000 $7,000/$14,000 $7,000/$14,000 Emergency Room Paid as In Network Paid as In Network Paid as In-Network Ambulance (emergency transport) All other Medical Services 50%, ded applies 50%, ded applies 60%, ded applies Retail Pharmacy (Note: OON Pharmacy is not a covered Not Covered Not Covered $15/$45/$60 benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) HMO Available POS Available X X X MC Available X See page 17 for endnotes. 14

17 Simply Savings GEORGIA (2-99 Employees) Plan or Calendar Year Calendar Calendar Calendar Calendar Deductible Type Embedded Embedded Embedded Embedded Lifetime Maximum Unlimited Unlimited Unlimited Unlimited IN NETWORK SERVICES Coinsurance 70% 70% 70% 100% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) $1,500/$4,500 $2,250/$6,750 $3,000/$9,000 $10,000/$10,000 * Annual Out-of-Pocket (OOP): Individual/Family $4,000/$12,000 $3,000/$9,000 $3,000/$9,000 $10,000/$10,000 Wellness On US SM Preventive Care, including Adult Physicals, $0, ded waived $0, ded waived $0, ded waived $0, ded waived Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well-Child Care (Age/Frequency schedules apply, includes $0, ded waived $0, ded waived $0, ded waived $0, ded waived coverage for immunizations) Physician Services Primary Care Physician Office visit $25, ded waived $40, ded waived $40, ded waived $35, ded waived Specialist Office Visit $50, ded waived $60, ded waived $60, ded waived 100%, ded applies Outpatient Mental Health * $50, ded waived $60, ded waived $60, ded waived 100%, ded applies Inpatient Services Hospital Inpatient 70% after $1,000/ admit, ded applies Mental Health Inpatient 70% after $1,000/ admit, ded applies Outpatient/Other Services 70% after $1,000/ admit, ded applies 70% after $1,000/ admit, ded applies 70% after $1,000/ admit, ded applies 70% after $1,000/ admit, ded applies 100%, ded applies 100%, ded applies Diagnostic Lab $25, ded waived $40, ded waived $40, ded waived 100%, ded applies Diagnostic X-ray $75, ded waived $100, ded waived $100, ded waived 100%, ded applies Diagnostic Complex Imaging 70%, ded applies 70%, ded applies 70%, ded applies 100%, ded applies (CAT, MRI, MRA/MRS and PET scans) Outpatient Surgery 70% after $500, ded 70% after $500, ded 70% after $500, ded 100%, ded applies applies applies applies Emergency Room $200, ded waived $200, ded waived $250, ded waived 100%, ded applies (Copay waived if admitted) Urgent Care $75, ded waived $75, ded waived $75, ded waived 100%, ded applies Ambulance (emergency transport) 70%, ded applies 70%, ded applies 70%, ded applies 100%, ded applies Outpatient Rehabilitative Therapy $50, ded waived $60, ded waived $60, ded waived 100%, ded applies (30 visits per year) Durable Medical Equipment 70%, ded applies 70%, ded applies 70%, ded applies 100%, ded applies ($5000 maximum per year) Chiropractic Services $50, ded waived $60, ded waived $60, ded waived 100%, ded applies (20 visits per year) PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) available at 2.5X copay for up to a 90-day supply $15/$45/$60 $15/$45/$70 $20/$50/$70 $20/$50/$70 Out-of-Network (OON) Services (OON) Services (POS/MC/PPO/Ind only-oon services do NOT apply to HMO plans) Coinsurance 50% 50% + 50% 70% Annual Deductible: Individual/Family $2,000/$6,000 $4,000/$12,000 $4,000/$12,000 $10,000/$10,000 (*deductible applies to OOP) Annual Out-of-Pocket (OOP): Individual/Family $5,000/$15,000 $6,000/$18,000 $6,000/$18,000 $15,000/$30,000 Emergency Room Paid as In Network Paid as In-Network Paid as In-Network Paid as In-Network Ambulance (emergency transport) All other Medical Services 50%, ded applies 50%, ded applies + 50%, ded applies 70%, ded applies Retail Pharmacy (Note: OON Pharmacy is not a covered Not Covered $15/$45/$70 Not Covered $20/$50/$70 benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) HMO Available POS Available X X X X MC Available X X See page 17 for endnotes. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 15

18 Georgia plan GUIDE Indemnity GEORGIA (2-99 Employees) 1900 Plan or Calendar Year Deductible Type Lifetime Maximum IN NETWORK SERVICES Calendar Embedded Unlimited Coinsurance 80% Annual Deductible: Individual/Family (* indicates deductible applies to OOP) $500/$1,500 Annual Out-of-Pocket (OOP): Individual/Family $7,000/$21,000 Wellness On US SM Preventive Care, including Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services. Well-Child Care (Age/Frequency schedules apply, includes coverage for immunizations) Physician Services Primary Care Physician Office visit Specialist Office Visit Outpatient Mental Health * Inpatient Services Hospital Inpatient Mental Health Inpatient Outpatient/Other Services Diagnostic Lab Diagnostic X-ray Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) Outpatient Surgery Emergency Room (Copay waived if admitted) Urgent Care Ambulance (emergency transport) Outpatient Rehabilitative Therapy (30 visits per year) Durable Medical Equipment ($5000 maximum per year) Chiropractic Services (20 visits per year) PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) available at 2.5X copay for up to a 90-day supply Out-of-Network (OON) Services Coinsurance Annual Deductible: Individual/Family (*deductible applies to OOP) Annual Out-of-Pocket (OOP): Individual/Family Emergency Room Ambulance (emergency transport) All other Medical Services Retail Pharmacy (Note: OON Pharmacy is not a covered benefit on POS plans) PLAN OPTIONS AVAILABLE (all open access no referrals) HMO Available POS Available MC Available $0, ded waived $0, ded waived 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies 80%, ded applies $15/$30/$50 Same as In Network Benefits Indemnity See page 17 for endnotes. 16

19 Endnotes This is a partial description of plans and benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage copayments indicate what Aetna is required to pay unless otherwise noted. NOTE: Some benefits are subject to limitations or visit maximums. Members or Providers may be required to precertify or obtain prior approval for certain services such as non-emergency hospital care. For a summary list of Limitations and Exclusions, refer to pages Federal Mental Health Parity applies to groups with 51+ employees effective October 1, Inpatient and outpatient mental health benefits shall be treated as any other illness and not subject to annual limits (except for Residential Treatment programs) on all plans 2-99, however different cost sharing may apply to outpatient mental health office visits services on certain plans with 51+ members. A 90-Day Transition of Coverage (TOC) for Prior Authorization and Step Therapy included on pharmacy plans. Transition of coverage for Prior Authorization and Step Therapy helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group s initial effective date, during which time Prior Authorization/Step Therapy requirements will not apply to certain drugs. Once the 90 calendar days has expired, Prior Authorization/Step Therapy edits will apply to all drugs requiring Prior Authorization/Step Therapy as listed in the formulary guide. Members, who have claims paid for a drug requiring Prior Authorization or Step Therapy during the Transition of Coverage period, may continue to receive this drug after the 90 calendar days and will not be required to obtain a Prior Authorization/Step Therapy or approval for a medical exception foœr this drug. You may choose providers in our network (physicians and facilities) or may visit an out-of-network provider. Typically, you will pay substantially more money out of your own pocket if you choose to use an out-of-network doctor or hospital. The out-of-network provider will be paid based on Aetna s recognized charge. This is not the same as the billed charge from the doctor. Aetna pays a percentage of the recognized charge, as defined in your plan. The recognized charge for out-of-network hospitals, doctors and other out-of-network health care providers is a percentage (100 percent or above) of the rate that Medicare pays them. You may have to pay the difference between the out-of-network provider s billed charge and Aetna s recognized charge, plus any coinsurance and deductibles due under the plan. Note that any amount the doctor or hospital bills you above Aetna s recognized charge does not count toward your deductible or out-of-pocket maximums. This benefit applies when you choose to get care out of network. When you have no choice in the doctors you see (for example, an emergency room visit after a car accident), your deductible and coinsurance for the in-network level of benefits will be applied, and you should contact Aetna if your doctor asks you to pay more. Generally, you are not responsible for any outstanding balance billed by your doctors in an emergency situation. + MC OA Plans 1905 and 1943 Out of Network Coinsurance is 60% for all services except Emergency Care and Emergency Ambulance services (paid at in network benefit levels). MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 17

20 Georgia plan GUIDE Plan Value $ $$ $$$ $$$$ POS OA 1945 (Simply Savings) POS OA 1932 (HSA Compatible) POS OA 1935 (HSA Compatible) MC OA 1945 (Simply Savings) POS OA 1944 (Simply Savings) POS OA 1943 (Simply Savings) MC OA 1935 (HSA Compatible) POS OA 1931 (HSA Compatible) POS OA 1942 (Simply Savings) MC OA 1943 (Simply Savings) HMO OA 1999 (Traditional) POS OA 1905 (Traditional) POS OA 1914 (100% Plan) HMO OA 1903 (Traditional) POS OA 1904 (Traditional) POS OA 1903 (Traditional) HMO OA 1913 (100% Plan) POS OA 1913 (100% Plan) MC OA 1905 (Traditional) MC OA 1914 (100% Plan) POS OA 1902 (Traditional) MC OA 1904 (Traditional) MC OA 1903 (Traditional) POS OA 1912 (100% Plan) MC OA 1913 (100% Plan) GA Indemnity

21 NOTES MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 19

22 Georgia plan GUIDE Aetna Avenue dental Overview Aetna Dental plans Small business decision makers can choose from a variety of plan design options that help you offer a dental benefits and dental insurance plan that s just right for your employees. The Mouth Matters SM Research suggests that serious gum disease, known as periodontitis, may be associated with many health problems. This is especially true if gum disease continues without treatment. 1,2 Now, here s the good news. Researchers are discovering that a healthy mouth may be important to your overall health. 1,2 Aetna Dental/Medical Integration SM (DMI) program,* available at no additional charge to plan sponsors that have both medical and dental coverages with Aetna, focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We proactively educate those at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care to visit the dentist. 2 Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full coverage for certain periodontal services. The Dental Maintenance Organization (DMO ) Members select a primary care dentist to coordinate their care from the available managed dental network. Each family member may choose a different primary care dentist and may switch dentists at any time via Aetna Navigator or with a call to Member Services. If specialty care is needed, a member s primary care dentist can refer the member to a participating specialist. However, members may visit orthodontists without a referral. There are virtually no claim forms to file, and benefits are not subject to deductibles or annual maximums. *DMI may not be available in all states. 1 MayoClinic.com. Oral health: A window to your overall health. Available online at dental/de Accessed May R.C. Williams, A.H. Barnett, N. Claffey, M. Davis, R. Gadsby, M. Kellett, G.Y.H. Lip, and S. Thackray. The potential impact of periodontal disease on general health: a consensus view. Current Medical Research and Opinion, Vol. 24, No. 6, 2008,

23 Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members services at a negotiated rate and will not balance-bill members.** PPO Max plan While the PPO Max dental insurance plan uses the PPO network, when members use out-of-network dentists the service will be covered based on the Aetna PPO fee schedule, rather than the reasonable and customary charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage. **Discounts for non-covered services may not be available. *** Dual Option does not apply to the Preventive and all Voluntary Dental plans. Discounts are not insurance. Freedom-of-Choice plan design option Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO Max plans on a monthly basis. One blended rate is paid. Members may switch between the plans on a monthly basis by calling Member Services. Plan changes must be made by the 15th of the month to be effective the following month. Dual Option*** plan In the Dual Option plan design the DMO may be packaged with any one of the PPO plans. Employees may choose between the DMO and PPO offerings at annual enrollment. Voluntary Dental option The Voluntary Dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Employers choose how the plan is funded. It can be entirely member-paid or employers can contribute up to 50 percent. Aetna Dental Preventive Care SM Plan The Preventive Care plan is a lowercost dental plan that covers preventive and diagnostic procedures. Members pay nothing for these services and may get a discount on the network dentist s charges for non-covered services when visiting an Aetna PPO dentist. This includes orthodontic work for adults and teeth whitening.** MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 21

24 Georgia plan GUIDE Aetna Small Group Dental Plans Available With an Aetna Medical Plan to Groups with 2-99 Eligible Employees Available Without Medical Plan (Dental Standalone) to Groups with 3-99 Eligible Employees DMO Plan 100/80/50 Option 1 DMO Option 2 Freedom of Choice Monthly selection between DMO and PPO Max DMO Plan 100/90/60 PPO Max Plan 100/70/40 Option 3 Freedom of Choice Monthly selection between DMO and PPO DMO Plan 100/90/60 PPO Plan 100/80/50 Office Visit Copay $5 $5 N/A $5 N/A Annual Deductible per Member does not apply to Diagnostic & Preventive Services None None $50; 3X Family Maximum None $50; 3X Family Maximum Annual Maximum Benefit Unlimited Unlimited $1,000 Unlimited $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% 100% Complete series 100% 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% 100% Space maintainers fixed 100% 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 90% 70% 90% 80% Resin filling 2 surfaces, anterior 80% 90% 70% 90% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 90% 70% 90% 80% Extraction of impacted tooth soft tissue 80% 90% 70% 90% 80% *Major Services Complete upper denture 50% 60% 40% 60% 50% Partial upper denture 50% 60% 40% 60% 50% Crown Porcelain with noble metal 50% 60% 40% 60% 50% Pontic Porcelain with noble metal 50% 60% 40% 60% 50% Inlay Metallic (3 or more surfaces) 50% 60% 40% 60% 50% Oral Surgery Removal of impacted tooth partially bony 50% 60% 40% 60% 50% Endodontic Services Bicuspid root canal therapy 50% 90% 40% 90% 80% Molar root canal therapy 50% 60% 40% 60% 50% Periodontic Services Scaling & root planing per quadrant 80% 90% 40% 90% 80% Osseous surgery per quadrant 50% 60% 40% 60% 50% *Orthodontic Services $2,300 copay $2,300 copay Not Covered $2,300 copay Not Covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply Does not apply * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Plan Options 1, 2 & 3 and the PPO in Plan Option 7. Access to negotiated discounts: On the PPO plans in Plan Options 2-7, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Options 1, 2 & 3 and on the PPO in Options 3 & 6. Out-of-Network plan payments are limited by geographic area on the PPO in Plan Options 3 & 5 to the prevailing fees at the 80th percentile and the 90th percentile in Plan Option 6. Plan Options 2 & 4; PPO Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. The DMO in Plan Option 1 can be offered with any one of the PPO plans in Plan Options 4-6 in a Dual Option package. Fixed dollar amounts on the DMO in Plan Options 1-3 including the Office Visit and Ortho copays are member responsibility. Orthodontic coverage is available on Plan Options 1, 2, 3, & 5 to groups with 10 or more eligibles and for Dependent Children Only. Adults and Dependent Children in Plan Option 6. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page

25 Aetna Small Group Dental Plans Available With an Aetna Medical Plan to Groups with 2-99 Eligible Employees Available Without Medical Plan (Dental Standalone) to Groups with 3-99 Eligible Employees Option 4 PPO Max PPO Max Plan 100/80/50 Option 5 Passive PPO PPO Plan 100/80/50 Option 6 Passive PPO PPO Plan 100/80/50 Option 7 Preventive Care PPO Max Plan 100/0/0 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member does not apply $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum None to Diagnostic & Preventive Services Annual Maximum Benefit $1,500 $1,500 $2,000 Unlimited Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers fixed 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% Not Covered Resin filling 2 surfaces, anterior 80% 80% 80% Not Covered Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% Not Covered Extraction of impacted tooth soft tissue 80% 80% 80% Not Covered *Major Services Complete upper denture 50% 50% 50% Not Covered Partial upper denture 50% 50% 50% Not Covered Crown Porcelain with noble metal 50% 50% 50% Not Covered Pontic Porcelain with noble metal 50% 50% 50% Not Covered Inlay Metallic (3 or more surfaces) 50% 50% 50% Not Covered Oral Surgery Removal of impacted tooth partially bony 50% 50% 50% Not Covered Endodontic Services Bicuspid root canal therapy 50% 50% 80% Not Covered Molar root canal therapy 50% 50% 50% Not Covered Periodontic Services Scaling & root planing per quadrant 50% 50% 80% Not Covered Osseous surgery per quadrant 50% 50% 50% Not Covered *Orthodontic Services Not Covered 50% 50% Not Covered Orthodontic Lifetime Maximum Does not apply $1,000 $1,000 Does not apply * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Plan Options 1, 2 & 3 and the PPO in Plan Option 7. Access to negotiated discounts: On the PPO plans in Plan Options 2-7, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Options 1, 2 & 3 and on the PPO in Options 3 & 6. Out-of-Network plan payments are limited by geographic area on the PPO in Plan Options 3 & 5 to the prevailing fees at the 80th percentile and the 90th percentile in Plan Option 6. Plan Options 2 & 4; PPO Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. The DMO in Plan Option 1 can be offered with any one of the PPO plans in Plan Options 4-6 in a Dual Option package. Fixed dollar amounts on the DMO in Plan Options 1-3 including the Office Visit and Ortho copays are member responsibility. Orthodontic coverage is available on Plan Options 1, 2, 3, & 5 to groups with 10 or more eligibles and for Dependent Children Only. Adults and Dependent Children in Plan Option 6. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 46. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 23

26 Georgia plan GUIDE Aetna Small Group Voluntary Dental Plans Available With an Aetna Medical Plan to Groups with 3-99 Eligible Employees Available Without Medical Plan (Dental Standalone) to Groups with 3-99 Eligible Employees Voluntary Option 1 DMO DMO Plan 100/80/50 Voluntary Option 2 Freedom of Choice Monthly selection between the DMO and PPO DMO Plan 100/90/60 PPO Max Plan 100/70/40 Voluntary Option 3 Freedom of Choice Monthly selection between the DMO and PPO DMO Plan 100/90/60 PPO Plan 100/80/50 Office Visit Copay $10 $10 N/A $10 N/A Annual Deductible per Member does not apply to Diagnostic & Preventive Services None None $75; 3X Family Maximum None $75; 3X Family Maximum Annual Maximum Benefit Unlimited Unlimited $1,000 Unlimited $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% 100% Complete series 100% 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 90% 70% 90% 80% Resin filling 2 surfaces, anterior 80% 90% 70% 90% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 90% 70% 90% 80% Extraction of impacted tooth soft tissue 80% 90% 70% 90% 80% *Major Services Complete upper denture 50% 60% 40% 60% 50% Partial upper denture (resin base) 50% 60% 40% 60% 50% Crown Porcelain with noble metal 50% 60% 40% 60% 50% Pontic Porcelain with noble metal 50% 60% 40% 60% 50% Inlay Metallic (3 or more surfaces) 50% 60% 40% 60% 50% Oral Surgery Removal of impacted tooth partially bony 50% 60% 40% 60% 50% Endodontic Services Bicuspid root canal therapy 80% 90% 40% 90% 80% Molar root canal therapy 50% 60% 40% 60% 50% Periodontic Services Scaling & root planing per quadrant 80% 90% 40% 90% 80% Osseous surgery per quadrant 50% 60% 40% 60% 50% *Orthodontic Services $2,400 copay $2,400 copay Not Covered $2,400 copay Not Covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply Does not apply * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Voluntary Plan Options 1, 2 & 3 and to the PPO in Voluntary Plan Option 5. Fixed dollar amounts on the DMO in Voluntary Plan Options 1-3 including the Office Visit and Ortho copays are member responsibility. Access to negotiated discounts: On the PPO plans in Voluntary Plan Options 2-5, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Voluntary Options 1, 2 & 3 and on the PPO in Voluntary Option 3. Voluntary Plan Options 2, 4 & 5; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. All voluntary plans require a minimum of 3 to enroll. Orthodontic coverage is available on the DMO in Voluntary Options 1-3 to groups with 10 or more eligibles and for dependent children only. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Voluntary Dual Option plans are not available. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page

27 Aetna Small Group Voluntary Dental Plans Available With an Aetna Medical Plan to Groups with 3-99 Eligible Employees Available Without Medical Plan (Dental Standalone) to Groups with 3-99 Eligible Employees Voluntary Option 4 PPO Max PPO Max Plan 100/80/50 Voluntary Option 5 Preventive Care PPO Max Plan 100/0/0 Office Visit Copay N/A N/A Annual Deductible per Member does not apply $75; 3X Family Maximum None to Diagnostic & Preventive Services Annual Maximum Benefit $1,500 Unlimited Diagnostic Services Oral Exams Periodic oral exam 100% 100% Comprehensive oral exam 100% 100% Problem-focused oral exam 100% 100% X-rays Bitewing single film 100% 100% Complete series 100% 100% Preventive Services Adult Cleaning 100% 100% Child Cleaning 100% 100% Sealants per tooth 100% 100% Fluoride application with cleaning 100% 100% Space maintainers 100% 100% Basic Services Amalgam filling 2 surfaces 80% Not Covered Resin filling 2 surfaces, anterior 80% Not Covered Oral Surgery Extraction exposed root or erupted tooth 80% Not Covered Extraction of impacted tooth soft tissue 80% Not Covered *Major Services Complete upper denture 50% Not Covered Partial upper denture (resin base) 50% Not Covered Crown Porcelain with noble metal 50% Not Covered Pontic Porcelain with noble metal 50% Not Covered Inlay Metallic (3 or more surfaces) 50% Not Covered Oral Surgery Removal of impacted tooth partially bony 50% Not Covered Endodontic Services Bicuspid root canal therapy 50% Not Covered Molar root canal therapy 50% Not Covered Periodontic Services Scaling & root planing per quadrant 50% Not Covered Osseous surgery per quadrant 50% Not Covered *Orthodontic Services Not Covered Not Covered Orthodontic Lifetime Maximum Does not apply Does not apply * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Voluntary Plan Options 1, 2 & 3 and to the PPO in Voluntary Plan Option 5. Fixed dollar amounts on the DMO in Voluntary Plan Options 1-3 including the Office Visit and Ortho copays are member responsibility. Access to negotiated discounts: On the PPO plans in Voluntary Plan Options 2-5, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Voluntary Options 1, 2 & 3 and on the PPO in Voluntary Option 3. Voluntary Plan Options 2, 4 & 5; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. All voluntary plans require a minimum of 3 to enroll. Orthodontic coverage is available on the DMO in Voluntary Options 1-3 to groups with 10 or more eligibles and for dependent children only. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Voluntary Dual Option plans are not available. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 46. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 25

28 Georgia plan GUIDE Out-of-State PPO Small Group Dental Plans Dental Plan Low Option No Ortho PPO Max Plan 100/80/50 Low Option Ortho PPO Max Plan 100/80/50 Office Visit Copay N/A N/A N/A Annual Deductible per Member (Does not apply to Diagnostic & Preventive Services) $50; 3X Family Maximum $50; 3X Family Maximum Medium Option No Ortho PPO Max Plan 100/80/50 $50; 3X Family Maximum Annual Maximum Benefit $1,000 $1,000 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% Comprehensive oral exam 100% 100% 100% Problem-focused oral exam 100% 100% 100% X-rays Bitewing single film 100% 100% 100% Complete series 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% Child Cleaning 100% 100% 100% Sealants per tooth 100% 100% 100% Fluoride application with cleaning 100% 100% 100% Space maintainers 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% Resin filling 2 surfaces, anterior 80% 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% Extraction of impacted tooth soft tissue 80% 80% 80% *Major Services Complete upper denture 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% Crown Porcelain with noble metal 50% 50% 50% Pontic Porcelain with noble metal 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% 50% Molar root canal therapy 50% 50% 50% Periodontic Services Scaling & root planing per quadrant 50% 50% 50% Osseous surgery per quadrant 50% 50% 50% *Orthodontic Services Not Covered 50% Not Covered Orthodontic Lifetime Maximum Does not apply $1,000 Does not apply * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Access to negotiated discounts: On all PPO Max plans, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 46. For out-of-state employees in all states except: Arkansas, Alaska, Hawaii, Idaho, Maine, Massachusetts, Montana, North Carolina, North Dakota, New Hampshire, New Mexico, South Dakota, Vermont, Wyoming. 26

29 Out-of-State PPO Small Group Dental Plans Dental Plan Medium Option Ortho PPO Max Plan 100/80/50 High Option No Ortho PPO Max Plan 100/80/50 Office Visit Copay N/A N/A N/A Annual Deductible per Member (Does not apply to Diagnostic & Preventive Services) $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,500 $2,000 $2,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% Comprehensive oral exam 100% 100% 100% Problem-focused oral exam 100% 100% 100% X-rays Bitewing single film 100% 100% 100% Complete series 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% Child Cleaning 100% 100% 100% Sealants per tooth 100% 100% 100% Fluoride application with cleaning 100% 100% 100% Space maintainers 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% Resin filling 2 surfaces, anterior 80% 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% Extraction of impacted tooth soft tissue 80% 80% 80% *Major Services Complete upper denture 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% Crown Porcelain with noble metal 50% 50% 50% Pontic Porcelain with noble metal 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% 50% Molar root canal therapy 50% 50% 50% Periodontic Services Scaling & root planing per quadrant 50% 50% 50% Osseous surgery per quadrant 50% 50% 50% *Orthodontic Services 50% Not Covered 50% Orthodontic Lifetime Maximum $1,000 Does not apply $1,000 High Option Ortho PPO Max Plan 100/80/50 $50; 3X Family Maximum * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Access to negotiated discounts: On all PPO Max plans, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 46. For out-of-state employees in all states except: Arkansas, Alaska, Hawaii, Idaho, Maine, Massachusetts, Montana, North Carolina, North Dakota, New Hampshire, New Mexico, South Dakota, Vermont, Wyoming. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 27

30 Georgia plan GUIDE Out-of-State PPO Voluntary Small Group Dental Plans Dental Plan Option 1 No Ortho PPO Max Plan 100/80/50 Office Visit Copay N/A N/A Annual Deductible per Member (Does not apply to Diagnostic & Preventive Services) $75; 3X Family Maximum Annual Maximum Benefit $1,000 $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% Comprehensive oral exam 100% 100% Problem-focused oral exam 100% 100% X-rays Bitewing single film 100% 100% Complete series 100% 100% Preventive Services Adult Cleaning 100% 100% Child Cleaning 100% 100% Sealants per tooth 100% 100% Fluoride application with cleaning 100% 100% Space maintainers 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% Resin filling 2 surfaces, anterior 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% Extraction of impacted tooth soft tissue 80% 80% *Major Services Complete upper denture 50% 50% Partial upper denture (resin base) 50% 50% Crown Porcelain with noble metal 50% 50% Pontic Porcelain with noble metal 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% Molar root canal therapy 50% 50% Periodontic Services Scaling & root planing per quadrant 50% 50% Osseous surgery per quadrant 50% 50% *Orthodontic Services Not Covered 50% Orthodontic Lifetime Maximum Does not apply $1,000 Option 1 Ortho PPO Max Plan 100/80/50 $75; 3X Family Maximum * Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Access to negotiated discounts: On all PPO Max plans, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 46. For out-of-state employees in all states except: Arkansas, Alaska, Hawaii, Idaho, Maine, Massachusetts, Montana, North Carolina, North Dakota, New Hampshire, New Mexico, South Dakota, Vermont, Wyoming. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. 28

31 NOTES MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 29

32 For groups with eligible employees, consult your Aetna Account Representative. Georgia plan GUIDE Aetna Avenue Life and Disability Overview Aetna Life Insurance Company (Aetna) Small Group packaged life and disability insurance or benefits plans include a range of flat-dollar insurance options bundled together in one monthly per-employee rate. These products are easy to understand and offer affordable benefits to help your employees protect their families in the event of illness, injury or death. You ll benefit from streamlined plan installation, administration and claims processing, and all of the benefits of our standalone life and disability products for small groups. Or, simply choose from our portfolio of group basic term life and disability insurance plans. Life insurance We know that life insurance is an important part of the benefits package you offer your employees. That s why our products and programs are designed to meet your needs for: Flexibility Added value Cost-efficiency Experienced support We help you give employees what they re looking for in lifestyle protection, through our selected group life insurance options. And we look beyond the benefit payout to include useful enhancements through the Aetna Life Essentials SM program. So what s the bottom line? A portfolio of value-packed products and programs to attract and retain workers while making the most of the benefit dollars you spend. Giving you (and your employees) what you want Employees are looking for cost-efficient plan features and value-added programs that help them make better decisions for themselves and their dependents. Our life insurance plans come with a variety of features including: Accelerated death benefit Also called the living benefit, the accelerated death benefit provides payment to terminally ill employees or spouses. This payment can be up to 75 percent of the life insurance benefit. Premium waiver provision Employee coverage may stay in effect up to age 65 without premium payments if an employee becomes permanently and totally disabled while insured due to an illness or injury prior to age 60. Optional dependent life This feature allows employees to add optional additional coverage for eligible spouses and children for employers with 10 or more employees. Our fresh approach to life With Aetna Life Essentials, your employees have access to programs during their active lives to help promote healthy, fulfilling lifestyles. In addition, Aetna Life Essentials provides for critical caring and support resources for often-overlooked needs during the end of one s life. And we also include value for beneficiaries and their loved ones well beyond the financial support from a death benefit. 30

33 AD&D Ultra AD&D Ultra is standardly included with our small group life and disability insurance or benefits plans and provides employees and their families with the same coverage as a typical accidental death and dismemberment plan and then some. This includes extra features at no additional cost to you, such as coverage for education or child-care expenses that make this protection even more valuable. Benefits include: Death Dismemberment Loss of Sight Loss of Speech Loss of Hearing Third-Degree Burns Paralysis Exposure and Disappearance Passenger Restraint and Airbag Education Benefit for Dependent Child and/or Spouse Child Care Benefit Coma Benefit Repatriation of Remains Benefit Total Disability Benefit Disabilit y insurance Finding disability services for you and your employees isn t difficult. Many companies offer them. The challenge is finding the right plan one that will meet the distinct needs of your business. Aetna understands this. Our in-depth approach to disability helps give us a clear understanding of what you and your employees need and then helps meet those needs. You ll get the right resources, the right support and the right care for your employees at the right time: Our clinically based disability model ensures claims and duration guidelines are fact-based with objective benchmarks. We offer a holistic approach that takes the whole person into account. We give you 24-hour access to claim information. We provide return-to-work programs to help ensure employees are back to work as soon as it s medically safe to do so. We employ vocational rehabilitation and ergonomic specialists who can help restore employees back to health and productive employment. Life and Disability products are underwritten or administered by Aetna Life Insurance Company. Integrated Health and Disability With our Integrated Health and Disability program, we can link medical and disability data to help anticipate concerns, take action and get your employees back to work sooner: Predictive modeling identifies medical members most likely to experience a disability, potentially preventing a disability from occurring or minimizing the impact for better outcomes. Health Insurance Portability and Accountability Act (HIPAA) compliant so medical and disability staff can share clinical information and work jointly with the employee to help address medical and disability issues. Referrals between health case managers and their disability counterparts help ensure better consistency and integration. The Integrated Health and Disability program is available at no additional cost when a member has both medical and disability coverage from Aetna. For a summary list of Limitations and Exclusions, refer to page 47. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 31

34 Georgia plan GUIDE Term Life Plan Options 2-9 Employees Employees Basic Life Schedule Flat $10,000, $15,000, $20,000, $50,000 Flat $10,000, $15,000, $20,000, $50,000, $75,000, $100,000, $125,000 Class Schedules Not Available Up to 3 classes (with a minimum requirement of 3 employees in each class) the benefit amount of the highest class cannot be more than 5 times the benefit amount of the lowest class even if only 2 classes are offered Premium Waiver Provision Premium Waiver 60 Premium Waiver 60 Age Reduction Schedule Original Life Amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Original Life Amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Accelerated Death Benefit Up to 75% of Life Amount for terminal illness Up to 75% of Life Amount for terminal illness Guaranteed Issue $20, employees $75, employees $100,000 Participation Requirements 100% 100% on non-contributory plans; With Medical 70% on contributory plans Standalone (26-50) 75% on contributory plans Contribution Requirements 100% Employer Contribution Minimum 50% Employer Contribution AD&D Ultra AD&D Schedule Matches Life Benefit Matches Life Benefit Additional Features Optional Dependent Term Life Passenger restraint and airbag, education benefit for your child and/or spouse, child care, repatriation of remains, coma, Total Disability, 365-day covered loss Spouse Amount Not Available $5,000 Child Amount Not Available $2,000 Available With an Aetna Medical Plan to Groups with 2-50 Eligible Employees Available With an Aetna Dental Plan to Groups with Eligible Employees Available Standalone (Without Medical or Dental Plans) to Groups with Eligible Employees For groups with eligible employees, consult your Aetna Account Representative. Passenger restraint and airbag, education benefit for your child and/or spouse, child care, repatriation of remains, coma, Total Disability, 365-day covered loss Disability Plan Options Short Term Benefits Plan Option 1 Plan Option 2 Plan Amount Choice of flat $100 increments to a maximum of $500 weekly Benefits Start Accident 1 Day 8 Days Benefits Start Illness 8 Days 8 Days Maximum Benefit Period 26 Weeks 26 Weeks Maternity Benefit Maternity treated same as any other disability but is subject to pre-existing. If pregnant before the effective date, the pregnancy is not covered unless she has prior creditable coverage. Pre-Existing Conditions Rule 3/12 3/12 Actively at Work Rule Applies Applies Other Income Offset Integration N/A N/A Choice of flat $100 increments to a maximum of $500 weekly Maternity treated same as any other disability but is subject to pre-existing. If pregnant before the effective date, the pregnancy is not covered unless she has prior creditable coverage. Other Income Offset Integration Earnings Loss of 20% or more Earnings Loss of 20% or more Definition of Disability Earnings Loss of 20% or more Earnings Loss of 20% or more Class Schedules Available With an Aetna Medical Plan to Groups with 2-50 Eligible Employees Available With an Aetna Dental Plan to Groups with Eligible Employees Available Standalone (Without Medical or Dental Plans) to Groups with Eligible Employees For groups with eligible employees, consult your Aetna Account Representative. Up to 3 classes (with a minimum requirement of 3 employees in each class) available for groups of 10 or more employees. The benefit amount of the highest class cannot be more than 5 times the benefit amount of the lowest class even if only two classes are offered. 32

35 Packaged Life and Disability Plan Options Basic Life Plan Design Low Option Low Option 2 Medium Option Medium Option 2 High Option Benefit Flat $10,000 Flat $15,000 Flat $20,000 Flat $25,000 Flat $50,000 Guaranteed Issue 2-9 Lives Lives Reduction Schedule $10,000 $10,000 Employee s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75 $15,000 $15,000 Employee s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75 Life and Disability products are underwritten or administered by Aetna Life Insurance Company. $20,000 $20,000 Employee s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75 $20,000 $25,000 Employee s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75 $20,000 $50,000 Employee s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75 Disability Provision Premium Waiver 60 Premium Waiver 60 Premium Waiver 60 Premium Waiver 60 Premium Waiver 60 Conversion Included Included Included Included Included Accelerated Death Benefit Up to 75% of benefit; 24 month acceleration Dependent Life Spouse $5,000; Child $2,000 AD&D ULTRA AD&D Ultra Matches Basic Life Benefit AD&D Ultra Additional Features Up to 75% of benefit; 24 month acceleration Spouse $5,000; Child $2,000 Matches Basic Life Benefit Up to 75% of benefit; 24 month acceleration Spouse $5,000; Child $2,000 Matches Basic Life Benefit Up to 75% of benefit; 24 month acceleration Spouse $5,000; Child $2,000 Matches Basic Life Benefit Seat Belt/Airbag, Education, Child Care, Repatriation, Coma, Total Disability, 365-Day Covered Loss Up to 75% of benefit; 24 month acceleration Spouse $5,000; Child $2,000 Matches Basic Life Benefit Disability Plan Design Monthly Benefit Flat $500; No offsets Flat $500; No offsets Flat $1,000; Offsets are Workers Compensation, any State Disability Plan and Primary and Family Social Security benefits. Elimination Period 30 days 30 days 30 days 30 days 30 days Definition of Disability Own Occupation: Earnings loss of 20% or more. Own Occupation: Earnings loss of 20% or more. Own Occupation: Earnings loss of 20% or more. Own Occupation: Earnings loss of 20% or more. First 24 months of benefits: Own Occupation Earnings Loss of 20% or more; Any reasonable occupation thereafter: 40% earnings loss. Benefit Duration 24 months 24 months 24 months 24 months 60 months Pre-Existing Condition 3/12 3/12 3/12 3/12 3/12 Limitation Types of Disability Occupational & Non-Occupational Occupational & Non-Occupational Occupational & Non-Occupational Occupational & Non-Occupational Occupational & Non-Occupational Separate Periods of Disability 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter Mental Health/ 24 months 24 months 24 months 24 months 24 months Substance Abuse Waiver of Premium Included Included Included Included Included OTHER PLAN PROVISIONS Employer Contribution 2-9 Lives 100% employer paid 10+ Lives % employer paid Minimum Participation 2-9 Lives 100% 10+ Lives 75% Eligibility Active Full Time Employees Class Schedules 2-9 Lives 100% employer paid 10+ Lives % employer paid 2-9 Lives 100% 10+ Lives 75% Active Full Time Employees 2-9 Lives 100% employer paid 10+ Lives % employer paid 2-9 Lives 100% 10+ Lives 75% Active Full Time Employees 2-9 Lives 100% employer paid 10+ Lives % employer paid 2-9 Lives 100% 10+ Lives 75% Active Full Time Employees 2-9 Lives 100% employer paid 10+ Lives % employer paid 2-9 Lives 100% 10+ Lives 75% Active Full Time Employees 2-9 Lives: Not Available; Lives: Up to 3 classes (with a minimum requirement of 3 employees in each class) the benefit amount of the highest class cannot be more than 5 times the benefit amount of the lowest class even if only two classes are offered. Rate Guarantee 1 year 1 year 1 year 1 year 1 year Rates PEPM $8.00 $10.00 $15.00 $16.00 $27.00 Available With an Aetna Medical Plan to Groups with 2-50 Eligible Employees Available With an Aetna Dental Plan to Groups with Eligible Employees Available Standalone (Without Medical or Dental Plans) to Groups with Eligible Employees For groups with eligible employees, consult your Aetna Account Representative. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 33

36 Georgia plan GUIDE Aetna Avenue Small Group Underwriting guidelines Georgia underwriting guidelines This material is intended for brokers and agents and is for informational purposes only. It is not intended to be all inclusive. Other policies and guidelines may apply. Note: State and Federal Legislation/Regulations, including Small Group Reform and HIPAA, take precedence over any and all Underwriting Rules. Exceptions to Underwriting Rules require approval of the Regional Underwriting Manager except where Head Underwriter approval is indicated. This information is the property of Aetna and its affiliates ( Aetna ), and may only be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing. Census Data Census data must be provided on all eligible, including COBRA eligible and Georgia State Continuation employees. Include name, date of birth, date of hire, gender, dependent status, and residence zip code. COBRA/Continuation eligibles should be included on the census and noted as COBRA/Continuation. If both husband and wife work for the same company and apply under one contract, rate will be based on the oldest adult. Case Submission Dates Groups with 2-3 eligible must have all completed paperwork into Aetna Underwriting 15 calendar days prior to the requested effective date. If not received by this date, the effective date will be moved to the next available effective date. Groups with 4-99 eligible must have all completed paperwork into Aetna Underwriting 5 business days prior to the requested effective date. If not received by this date, the effective date will be moved to the next available effective date. Dependent Eligibility Coverage is available to Domestic Partners (affidavits required) on groups of 20 or more eligible employees. An employee s spouse is eligible to enroll. If both husband and wife work for the same company, then they may enroll together or separately. Children can only be covered under one parent s plan. Dependent children, as defined in plan documents in accordance with state and federal law, are eligible for medical and dental coverage up to age 26. Grandchildren are eligible if court ordered. For dependent life, dependents are eligible from 14 days of age up to their 19th birthday, or up to their 23rd birthday, if in school. Dependent children are not eligible for AD&D or Disability coverage. For Medical and Dental, dependents must enroll in the same benefits as the employee (participation is not required). Employees may select coverage for eligible dependents under the Dental plan even if they select single coverage under the Medical plan. See product-specific Life/AD&D and Disability guidelines under Product Specifications. Consumer Flex Choice New Business Employers may select Consumer Flex Choice (all plans) which allows employers to select an unlimited number of plan options within the current product portfolio. Eligibility: Groups with 4 to 99 Eligible Employees may participate. Employer Contribution: The employer is required to contribute a minimum of 50% of the Employee-Only cost of the OA POS 1945, if the group is located in an OA POS service area. Otherwise contributions will be based on the OA MC Employee Participation: > For non-contributory plans, 100% participation is required, excluding valid waiver. > For contributory plans, 75% of eligible employees must enroll, excluding valid waivers. Each plan chosen must have a minimum of one employee enrolled for the plan to be offered and available for newly hired employees, until the Employer s next renewal. Effective Date Renewing Business Employer may select Consumer Flex Choice at renewal. Same rules apply as New Business. The effective date must be the 1st or the 15th of the month. The effective date requested by the employer may be up to 60 days in advance. 34

37 Employee Eligibility Employer Eligibility Eligible employees are those employees who are permanent and work on a full-time basis with a normal work week of at least 25 hours, and who have met any authorized waiting period requirements. Employees/Individuals who are not eligible for coverage include 1099 contractors, temporary, seasonal, substitute, uncompensated employees, volunteers, an inactive owner, shareholder only, officer who is not active, a managing member who is not active, an investor only, or a silent partner. Coverage must be extended to all employees meeting the above conditions, unless they belong to a union class excluded as the result of a collective bargaining arrangement. While they must be included in the count in determining whether or not the group is a small employer, the employer may carve out union employees as an excluded class. If the employer s Employee Eligibility Criteria definition differs from the above definition (more than 25 hours), this should be indicated on the Employer Application at the time of new business submission. Note, the normal work week cannot be less than 25 hours. Employees are eligible to enroll in the dental plan even if they do not select medical coverage and vice versa Employees 1099 Employees are not defined as an eligible employee, however Aetna will allow 1099 employees to enroll subject to the following guidelines: Employees reported on the IRS 1099 forms who meet Aetna s standard criteria for determining 1099 status; and Only if all 1099 employees are offered coverage; and As long as the 1099 employees comprise less than 25% of total eligibles in the group. Retirees Retiree coverage is not available under 50 lives. For groups of over 50 eligible lives, Retirees cannot comprise more than 10% of the group. Medicare eligible retirees who are enrolled in an Aetna Medicare Plan are eligible to enroll in Standard Dental Plans in accordance with these Dental Underwriting Guidelines. Retirees are not eligible for Life or Disability insurance coverage. Medicare Retiree coverage is available for Medicare eligible retirees and/or active Medicare eligible in accordance with the Medicare Retiree Underwriting Guidelines. COBRA/State continuees COBRA/State Continuation coverage will be extended in accordance with the federal/state law. COBRA and state continuees are included in the Medical underwriting of the group. Health questionnaire information must be provided on COBRA (EEs) and state continuees along with the rest of the group. COBRA/State continuees qualifying event, length, start and end date must be provided. COBRA and state continuees are not eligible for Life and Disability coverage. COBRA/State eligible enrollees are required to be included on the census (not eligible for Life or Disability). COBRA/State qualifying event, length, start and end date must be provided. Note: Employees reported on the IRS 1099 forms and COBRA continuees are not to be included for purpose of counting employees to determine the size of the group. Once the size of the group has been determined and it is determined that the law is applicable to the group, 1099 employees and COBRA continuees can be included for coverage subject to normal underwriting guidelines. A single employer, firm, corporation, partnership, sole proprietor, or other legitimate group, with at least 2 and not more than 50 total eligible employees, members, or enrollees (not including dependents) on the initial application date and on average during the calendar quarter preceding application. In determining the number of eligible employees, members or enrollees, companies that are affiliated companies are eligible to file a combined tax return for purposes of taxation by this state, or are subsidiaries of another company and covered under the parent company s group health insurance contract or policy, shall be considered one group. Subsequent to the issuance of a health insurance policy or contract to a small group and for the purpose of determining continued eligibility, the size of a small group shall be determined annually. Except as otherwise specifically provided, provisions of this Rule shall continue to apply at least until the renewal date following the date the small group no longer meets the requirements of this definition. For the purposes of applying this rule, a small group shall be subject to this rule if: 1. The majority of insured employees, members, or enrollees in the group are employed or reside in this state; or 2. If no state contains a majority of the insured employees, members, or enrollees in a group, the primary business location of the employer is in this state. Groups with 51 to 99 eligible employees are not subject to Small Group Reform and are therefore not Guaranteed Issue. Medical plans can be offered to sole proprietors, partnerships or corporations. Organizations must not be formed solely for the purpose of obtaining health coverage. Taft Hartley groups and closed groups are not eligible. Dental and Disability have ineligible industries which are listed separately under Product Specifications. The Dental ineligible industry list does not apply when dental is sold in combination with Medical. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 35

38 Georgia plan GUIDE Tax Documentation Groups 2 to 9 eligibles and 10+ without prior coverage must provide a current copy of the following: DOL-4 Form; or Form 941 and payroll summary. Employees who have terminated, work part-time or are newly hired should be noted accordingly on the DOL-4. Any handwritten comments added to the DOL-4 must be signed and dated by the employer. This may be requested at the discretion of the underwriter. Newly hired employees should be written in on the Quarterly Wage & Tax Statement and signed by the employer. Payroll records may be requested at the discretion of the underwriter. Proprietors, Partners or Officers of the business who do not appear on the DOL-4 or payroll must submit one of the following identified documents: Sole Proprietor Franchise Limited Liability Company (operating as a Sole Proprietor) IRS Form 1040 along with Schedule C (Form 1040) IRS Form 1040 along with Schedule SE (Form 1040) IRS Form 1040 along with Schedule F (Form 1040) IRS 1040 along with Schedule K1 (Form 1065) Any other documentation the owner would like to provide to determine eligibility Partner Partnership Limited Liability Partnership Corporate Officer Limited Liability Company (operating as C Corp) C-Corporation Personal Service Corporation S-Corporation IRS Form 1065 Schedule K-1 IRS Form 1120 S Schedule K-1 along with Schedule E (Form 1040) Partnership agreement if established within 2 years eligible partners must be listed on agreement Any other documentation the owner would like to provide to determine eligibility IRS Form 1120 S Schedule K1 along with Schedule E (Form 1040) IRS Form 1120 W (C-Corp & Personal Service Corp) 1040 ES (Estimated Tax) (S-Corp) IRS Form 8832 (Entity classification as a corporation) W2 Articles of Incorporation if established within 2 years - corporate officers must be listed Any other documentation the owner would like to provide to determine eligibility Initial Premium Payment Newly Formed Business (less than 3 months) Non-profit groups may provide payroll documents as long as they also submit the appropriate form detailing their non-profit status. Groups that do not file a DOL-4, wage and tax statement must complete the Employee Eligibility Verification Form. The initial premium payment should be in the amount of the first month s premium and drawn on the company check or processed via an Electronic Funds Transfer. The initial premium payment is not a binder check and does not bind Aetna to provide coverage. If the request for coverage is withdrawn or denied due to business ineligibility, participation and/or contributions not met, the premium will be returned to the employer. If the initial premium payment is returned for non-sufficient funds, coverage will be terminated retroactive to the effective date. The following documentation must be provided for consideration. Newly formed businesses may be considered at the discretion of the underwriter if the following are provided: Sole Proprietor: A copy of the Business License (not a professional license). Partnership or Limited Liability Partnership: A copy of the Partnership agreement. Limited Liability Company: A copy of the Articles of Organization and the Operating Agreement to include the signature page of all officers. Corporation: A copy of the Articles of Incorporation to include the signature page of all officers (must be followed up with a copy of the Statement of Information within 30 days of filing with the State). Each newly formed business must also provide: Proof of Employer Identification Number/Federal Tax ID Number; and Quarterly Wage and Tax statement. If not available, when will one be filed; and The most recent two consecutive weeks worth of payroll records, which includes hours worked, taxes withheld, check number and wages earned; or A letter from a CPA with the following information: A list of all employees, to include owners, partners, officers (full time and part time) Number of hours worked by each employee Weekly salary for each employee Date of hire for each employee Have payroll records been established? Will a Quarterly Wage and Tax Statement UC018/UC020 be filed? If so, when? Groups that are not subject to Guarantee Issue may be declined. 36

39 Plan Change Ancillary Additions Replacing Other Group Coverage Two or More Companies Affiliated, Associated or Multiple Companies, Common Ownership Waiting Period Rating Information Signature Dates Packaged Life/Disability must be requested 30 days prior to the desired effective date. Dental plans must be requested 30 days prior to the desired effective date. Non-packaged plan changes are available upon renewal. The future renewal date of the ancillary products will be the same as the Medical plan renewal date. Provide a copy of the current billing statement that includes the account summary along with the prior year s billing statement. The employer should be told not to cancel any existing medical coverage until they have been notified of approval from the Aetna Underwriting unit. Employers who have more than one business with different Tax Identification Numbers (TINs) may be eligible to enroll as one group if the following are met: One owner has controlling interest of all business to be included; or The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851, a combined tax return for all companies to be included. If they are eligible but choose not to file Form 851, please indicate as such. A copy of the latest filed tax return must be provided; and All businesses filed under one combined tax return must be enrolled as one group. For example, if the employer has three businesses and files all three under one combined tax return, then all three businesses must be enrolled for coverage. If the request is for only 2 of the 3 businesses to be enrolled, the group will be considered a carve-out, will not be Guarantee Issue, and could be declined. The two or more groups may have multiple Standard Industrial Classification Codes (SIC); however, rates will be based on the SIC code for the group with the majority of employees. A completed Common Ownership form needs to be submitted. At initial submission of the group, the benefit waiting period may be waived upon the employer s request. This should be checked on the Employer Application. The benefit waiting period for future employees may be none, 1, 2, 3, 4, 5, 6, or 12 months. The eligibility date for new hires will be the first day of the policy month following the waiting period. Example: Group A effective date is July 1st; employees will be issued an effective date of the 1st of the month following the chosen waiting period. Group B effective date is July 15th, employees will be issued an effective date of the 15th of the month following the chosen waiting period. Two benefit waiting periods may be selected and must be consistently applied within a class of employees. A change to the benefit waiting period may only be made on the case anniversary date. No retroactive changes will be allowed. Rates are based on final enrollment and require that: No portion of the member s cost sharing, including but not limited to, copayments, deductibles and/or coinsurance balances will be subsidized or funded by the employer, with the exception of a federally-qualified Health Reimbursement Account (HRA), or Health Savings Account (HSA), whether insured or self-funded, including but not limited to a partially self-funded Section 105 wrap around, now or in the future; and Employer is not funding the deductible of the quoted health plan through an HRA or HSA arrangement in excess of 50% annually. All quotes are subject to change based on additional information that becomes available in the quoting process and during case submission/installation, including any change in census. All rates will be quoted on a 4-tier structure: single, couple, employee plus child(ren), family. The Aetna Employer Application and all employee applications must be signed and dated prior to and within ninety (90) days of the requested effective date. All employee applications must be completed by the employee himself/herself. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 37

40 Georgia plan GUIDE PRODUCT SPECIFICATIONS Product Availability Excluded Class/ Carve Outs Employer Contribution Medical Dental Life/AD&D Packaged Life & Disability 2 eligible employees 2 to 9 eligibles If packaged with Medical. 10 to 25 eligibles If packaged with Medical or Dental. 2 to 99 eligibles May be written standalone or with ancillary coverages as noted in the following columns. Only non-occupational injuries and disease will be covered. 24-hour coverage is available for owners. Union employees are the only class of employees that may be excluded. However, union employees are included in the total count of eligible employees in determining the case size. 2 to 3 eligibles 100% of the employee premium. 4 to 99 eligibles 50% of the employee-only cost or 50% of the total cost of the plan. Value Pick Plans For groups of 4 or more enrolled employees, 25% of the employee premium or $50 per employee. Coverage can be denied based on inadequate contributions. Standard All plans if packaged with Medical. Voluntary Not available. 3 to 99 eligible employees Standard and Voluntary plans are available. Standalone available. Voluntary Dual Option plans are not permitted. Orthodontic coverage is available for groups of 10 or more eligible employees with a minimum of 5 enrolled for both Standard and Voluntary plans. Union employees may be excluded. Standard Dental 2 to 99 eligibles 25% of the total cost of the plan or 50% of the cost of employee only coverage. Voluntary Dental Employer contribution of less than 50% of the cost of the employee-only coverage. Employee-Pay-All plans are permitted. Standard and Voluntary Coverage can be denied based on inadequate contributions. 26 to 50 eligible employees on a standalone basis. A plan sponsor cannot purchase both Life and Packaged Life and Disability plans. For Groups of 51 to 99, contact your Aetna Account Executive. Union employees may be excluded. 2 to 9 eligibles 100% of the total cost. 10 to 50 eligibles At least 50% of the total cost (excluding Optional Dependent Term Life). Coverage can be denied based on inadequate contributions. For Groups of 51 to 99, contact your Aetna Account Executive. Disability 2 to 9 eligibles If packaged with Medical. 10 to 25 eligibles If packaged with Medical or Dental. 26 to 50 eligibles on a standalone basis. Groups are ineligible for coverage if 60% or more of eligible employees or 60% or more of eligible payroll are for employees over 50 years old. A plan sponsor cannot purchase both Disability and Packaged Life and Disability plans. Available to employees only. For Groups of 51 to 99 contact your Aetna Account Executive. Union employees may be excluded. 2 to 9 eligibles 100% of the total cost. 10 to 50 eligibles At least 50% of total cost of the plan. Coverage can be denied based on inadequate contributions. For Groups of 51 to 99, contact your Aetna Account Executive. 38

41 PRODUCT SPECIFICATIONS Participation Medical Dental Life/AD&D Packaged Life & Disability For non-contributory plans, 100% participation is required, excluding valid waivers.* For contributory plans, 75% of eligibles must enroll, excluding valid waivers.* Round down to the nearest whole number. Example: 12 minus 3 valid waivers = 9. 9 x 75% = 6.75 = 6 must enroll Value Pick Plans 50% of eligible employees must enroll, excluding valid waivers, rounding to the nearest whole number. All employees waiving coverage must complete the waiver section and provide proof of other coverage by submitting a copy of the ID card. Proof of other coverage is needed only for the percentage needed to meet participation. Dependent participation is not required. Coverage can be denied based on inadequate participation. For non-contributory plans, 100% participation is required, excluding those with other qualifying dental coverage. Standard: 2 to 3 eligible employees 100% participation is required, excluding those with other qualifying existing dental coverage. 4 to 99 eligible employees 75% participation is required, excluding those with other qualifying existing dental coverage. A minimum of 50% of total eligible employees must enroll in the Dental plan. A minimum of two (2) employees must enroll. Voluntary: 3 to 99 eligible employees 25% participation, excluding those with other qualifying existing dental coverage or a minimum of 3 enrollees (5 enrollees for orthodontia coverage) whichever is greater is required. Standalone Dental: 75% participation is required excluding those with other qualifying dental coverage. A minimum of 50% of total eligible employees must enroll in the Dental plan. Employees may select coverage for eligible dependents under the dental plan even if they elected single coverage on the medical plan or vice versa. Coverage can be denied based on inadequate participation. For non-contributory plans, 100% participation is required. 2 to 9 eligibles 100% participation is required. 10 to 50 eligibles 75% participation is required. COBRA continuees are not eligible for Life. Employees may elect Life or Packaged Life/Disability even if they do not elect medical coverage and the group must meet the required participation percentage. If not, then Life or Packaged Life/Disability will be declined for the group. Example: 9 employees 3 waiving Medical 9 must enroll for Life or Packaged Life/Disability Coverage can be denied based on inadequate participation. For Groups of 51 to 99, contact your Aetna Account Executive. Disability For non-contributory plans, 100% participation is required. For contributory plans 2 to 9 employees 100% participation is required. 10 to 50 employees 75% participation is required. COBRA continuees are not eligible for Disability. Employees may elect Disability coverage even if they do not elect Medical coverage and the group must meet the required participation percentage. If not, then Disability will be declined for the group. Example: 9 employees 3 waiving Medical 9 must enroll for Disability Coverage can be denied based on inadequate participation. For Groups of 51 to 99, contact your Aetna Account Executive. * Valid waivers include spousal/parental group coverage, Medicare/Medicaid, Champus/ChampVA, Military coverage, Retiree coverage, or Association coverage (for doctors/lawyers covered under an association who want to cover their employees). Individual coverage and Limited Liability plans do not constitute valid waivers. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 39

42 Georgia plan GUIDE PRODUCT SPECIFICATIONS Out-of-State Employees (residing outside Georgia) Medical Underwriting Late Applicants Medical Dental Life/AD&D Packaged Life & Disability Out-of-state employees must be enrolled in an out-of-state MC OA plan if available; otherwise, an indemnity plan. A Georgia group with 2 to 50 eligibles cannot be denied based on medical conditions; however, rates may be adjusted for known medical conditions. A group with 51 to 99 eligibles will be required to provide individual medical questionnaires. These cases may be declined or rated up. Groups that have been terminated for non-payment by Aetna must pay all premiums still owed on the prior Aetna plan before the new plan will be issued. Medical claims will be reviewed for all individuals who had prior Aetna coverage along with the health information provided on the application and included in the overall medical assessment of the group. Out-of-state (OOS) employees must be enrolled in an OOS PPO Dental plan if available; otherwise, an Indemnity Dental plan. OOS PPO Dental is not available in the following states: AR, AK, HI, ID, ME, MT, NC, ND, NH, NM, SD, VT and WY. Not applicable Out-of-state employees are eligible for the same benefit, same rates as elected by the home office. Note: The home office would have to be sitused in a state that we offer Life and/or Packaged Life/Disability. All timely entrants will be issued the Guaranteed Issue amount unless reinstatement or restoration of coverage is requested. Employees wishing to obtain insurance amounts above the Guaranteed Issue amounts listed below will be required to submit Evidence of Insurability (EOI) which means they must complete an individual health statement and may have to submit to medical evidence. Disability Out-of-state employees are eligible for the same benefit, same rates as elected by the home office. Note: The home office would have to be sitused in a state that we offer Life and/or Packaged Life/Disability. All timely entrants will be issued the Guaranteed Issue amount unless reinstatement or restoration of coverage is requested and/ or they are late entrants. An employee or dependent who enrolls for coverage more than 31 days from the date first eligible or 31 days of the qualifying event is considered a late enrollee. Applicants without a qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are subject to the Late Entrant guidelines as noted below. Voluntary cancellation of coverage is NOT a qualifying event. For example, if a spouse is covered through his/her employer and voluntarily cancels the coverage, it is not a qualifying event to be added to the other spouse s plan. The spouse who cancelled the coverage must wait until the next plan anniversary date to be eligible to be added. Life late enrollee example: Group has $50,000 life with $20,000 guaranteed issue limit. Late enrollee enrolling for $50,000 would not automatically get the $20,000. Since the applicant is late, they must medically qualify for the entire $50,000. Late applicants will be deferred to the next plan anniversary date of the group and may reapply for coverage 30 days prior to the anniversary date. An employee or dependent may enroll at any time; however, coverage is limited to Preventive & Diagnostic services for the first 12 months. No coverage for most Basic and Major Services for first 12 months (24 months for Orthodontics). Late Entrant provision does not apply to enrollees less than age 5. Late applicants will be deferred to the next plan anniversary date of the group and may reapply for coverage 30 days prior to the anniversary date. The applicant will be required to complete an individual health statement/ questionnaire and provide Evidence of Insurability (EOI). Late applicants will be deferred to the next plan anniversary date of the group and may reapply for coverage 30 days prior to the anniversary date. The applicant will be required to complete an individual health statement/questionnaire and provide EOI. 40

43 PRODUCT SPECIFICATIONS Standard Industrial Classification Code (SIC) Medical Dental Life/AD&D Packaged Life & Disability Basic Term Life All industries are eligible. Packaged Life/Disability The following industries are not eligible. All industries are eligible. The employer should provide the SIC code (4-digit number) or NAIC state code 6-digit code) filed with the state on the business tax return and/or the Workers Compensation form. The following industries are not eligible when Dental is sold standalone or packaged only with Life. This list does not apply when Dental is sold in combination with Medical. SIC Range SIC Description Employment Agencies 7911Dance Studios, Schools 7933 Bowling Centers Theatrical Producers, Bands, Orchestras, Actors Professional Sports Clubs & Producers, Race Tracks 7991Physical Fitness Facilities Public Golf Courses, Amusements, Membership Sports & Recreation Clubs 7999Miscellaneous Amusement/ Recreation Professional Membership Organizations, Labor Unions, Civic Social and Fraternal Orgs, Political Orgs 8611Business Associations 8661Religious Organizations 8699Miscellaneous Membership Org 8811 Private Households 8999Miscellaneous Services SIC Range SIC Description Mining Explosives, Bombs & Pyrotechnics Asbestos Products Primary Metal Ind Fire Arms & Ammo 5921 Liquor Stores 6211 Security Brokers 6531 Real Estate Agents 7381 Detective Service Automotive Repair Service Motion Picture/ Amusement & Rec Doctors Offices/ Clinics Membership Assoc Private Households 9999Non-classified Establishments Disability See Life column for the industries are not eligible. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 41

44 Georgia plan GUIDE DENTAL ONLY Coverage Waiting Period Product Packaging Open Enrollment Options Sales Reinstatement (applies to Voluntary Plans only) For Major and Orthodontic Services employees must be an enrolled member of the employer s plan for 1 year before becoming eligible. There is no waiting period for DMO. Discount plans do not qualify as previous coverage. Virgin group (no prior coverage) The waiting periods apply to employees at case inception as well as any future hires. Takeover/Replacement cases (prior coverage) you must provide a copy of the last billing statement and schedule of benefits in order to provide credit. If a group s prior coverage did not lapse more than 90 days prior, the waiting periods are waived. In order for the waiting period to be waived, the group must have had a dental plan in place that covered Major (and Ortho, if applicable) immediately preceding our takeover of the business. Example: Prior Major coverage but no Ortho coverage. Aetna plan has coverage for both Major and Ortho. The Waiting Period is waived for Major services but not for Ortho services. Voluntary Dental Dual Option sales are not permitted. All Voluntary plans must be a single plan sold. All Voluntary plans require a minimum of 3 to enroll. Orthodontic coverage is available with 10 or more eligibles for dependent children only. A minimum of 5 employees must enroll. Standard DMO can be either sold standalone or packaged with any PPO Option as a Dual Option with a minimum of 2 enrolled. PPO can be sold standalone or packaged with the DMO as a Dual Option with a minimum of 2 enrolled. Freedom-of-Choice cannot be packaged with any other option. It must be the only plan sold. Orthodontic coverage is available with 10 or more eligibles for dependent children only. A minimum of 5 employees must enroll. An employee or dependent can enroll at any time but is subject to the Dental Late Entrant provision if enrollment occurs other than within 31 days of first becoming eligible unless a qualifying life event has occurred or the enrollee is less than age 5. Option sales alongside another dental carrier are not allowed. All dental plans must be sold on a full replacement basis. Members once enrolled who have previously terminated their coverage by discontinuing their contributions may not re-enroll for a period of 24 months. All coverage rules will apply from the new effective date including, but not limited to, the Coverage Waiting Period. 42

45 LIFE AND DISABILITY ONLY Job Classification (Position) Schedules Guaranteed Issue Coverage Actively-at-Work Continuity of Coverage (no loss/no gain) Evidence of Insurability (EOI) Varying levels of coverage based on job classifications are available for groups with 10 or more lives. Up to 3 separate classes are allowed (with a minimum requirement of 3 employees in each class). Items such as probationary periods must be applied consistently within a class of employee. The benefit for the class with the richest benefit must not be greater than five (5) times the benefit of the class with the lowest benefit even if only 2 classes are offered. For example, a schedule may be structured as follows: Position/Job Class Basic Term Life Amount Disability Packaged Life/Disability Executives $50,000 Flat $500 High Option Managers/Supervisors $20,000 Flat $300 Medium Option All Other Employees $10,000 Flat $200 Low Option Aetna provides certain amounts of Life insurance to all timely entrants without requiring an employee to answer any Medical questions. These insurance amounts are called Guaranteed Issue. Employees wishing to obtain increased insurance amounts will be required to submit Evidence of Insurability which means they must complete a Medical questionnaire and may be required to provide medical records. On-time enrollees who do not meet the requirements of Evidence of Insurability will receive the Guaranteed Issue Life amount. Late enrollees must qualify for the entire amount and are not guaranteed any coverage. Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day. The employee will not lose coverage due to a change in carriers. This protects employees who are not actively at work during a change in insurance carriers. If an employee is not actively at work, Aetna will waive the actively-at-work requirement and provide coverage, except no benefits are payable if the prior plan is liable. EOI is required when one or more of the following conditions exist: 1) Life insurance coverage amounts requested are above the Guaranteed Standard Issue Limit. 2) Coverage is not requested within 31 days of eligibility for contributory coverage. 3) New coverage is requested during the anniversary period. 4) Coverage is requested outside of the employer s anniversary period due to qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.). 5) Reinstatement or restoration of coverage is requested. 6) Requesting Life or Disability at the individual level for a late enrollee even if enrolling on the case anniversary date. Late enrollees are not eligible for the Guarantee Issue Limit. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 43

46 Georgia plan GUIDE Limitations and exclusions Medical These plans do not cover all health care expenses and include exclusions and limitations. Employers and members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design purchased. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents Charges related to any eye surgery mainly to correct refractive errors Cosmetic surgery, including breast reduction Custodial care Dental care and X-rays Donor egg retrieval Experimental and investigational procedures Hearing aids Immunizations for travel or work Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents Medical expenses for a pre-existing condition are not covered (full postponement rule) for the first 365 days after the insured s enrollment date; look-back period for determining a pre-existing condition (conditions for which diagnosis, care or treatment was recommended or received) is 180 days prior to the enrollment date, the pre-existing condition limitation period will be reduced by the number of days of prior creditable coverage the member has as of the enrollment date Nonmedically necessary services or supplies Orthotics Over-the-counter medications and supplies Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling Special duty nursing Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. Vision examinations and refractions. 44

47 Aetna Open Access HMO/ Aetna Open Access Point of Service/Aetna Open Access Managed Choice/Indemnity pre-existing conditions exclusion provision This plan imposes a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditable coverage) and may not be applicable to you. A preexisting conditions exclusion means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within six months. Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the six-month period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 12 months from your first day of coverage or, if you were in a waiting period, from the first day of your waiting period. If you had prior creditable coverage within 90 days immediately before the date you enrolled under this plan, then the preexisting conditions exclusion in your plan, if any, will be waived. If you had no prior creditable coverage within the 90 days prior to your enrollment date (either because you had no prior coverage or because there was more than a 63-day gap from the date your prior coverage terminated to your enrollment date), we will apply your plan s pre-existing exclusion. In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any Certificates of Creditable Coverage you have. Please contact your Aetna Member Services representative at AETNA ( ) if you need assistance in obtaining a Certificate of Creditable Coverage from your prior carriers or if you have any questions on the information noted above. The pre-existing conditions exclusion does not apply to pregnancy nor to an individual under the age of 19. Note: For late enrollees, coverage will be delayed until the plan s next open enrollment; the pre-existing exclusion will be applied from the individual s effective date of coverage. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 45

48 Georgia plan GUIDE Limitations and exclusions Dental Listed below are some of the charges and services for which these dental plans do not provide coverage. For a complete list of exclusions and limitations, refer to the plan documents. Dental services or supplies that are primarily used to alter, improve or enhance appearance. Experimental services, supplies or procedures. Treatment of any jaw joint disorder, such as temporomandibular joint disorder. Replacement of lost, missing or stolen appliances and certain damaged appliances. Those services that Aetna defines as not necessary for the diagnosis, care or treatment of a condition involved. Members who do not enroll within the first 31 days of becoming eligible may be subject to a late entrant penalty. The waiting period may be waived in certain situations. Specific service limitations DMO plans: Oral exams (4 per year) PPO plans: Oral exams (2 routine and 2 problem-focused per year) All plans: Bitewing X-rays (1 set per year) Complete series X-rays (1 set every 3 years) Cleanings (2 per year) Fluoride (1 per year; children under 16) Sealants (1 treatment per tooth, every 3 years on permanent molars; children under 16) Scaling & root planing (4 quadrants every 2 years) Osseous surgery (1 per quadrant every 3 years) All other limitations and exclusions in the plan documents. 46

49 AD&D Ultra This coverage is only for losses caused by accidents. No benefits are payable for a loss caused or contributed to by: A bodily or mental infirmity A disease, ptomaine or bacterial infection* Medical or surgical treatment* Suicide or attempted suicide (while sane or insane) An intentionally self-inflicted injury A war or any act of war (declared or not declared) Commission of or attempt to commit a criminal act Use of alcohol, intoxicants or drugs, except as prescribed by a physician, an accident in which the blood alcohol level of the operator of a motor vehicle meets or exceeds the level at which intoxication would be presumed under the law of the state where the accident occurred shall be deemed to be caused by the use of alcohol Intended contact with nuclear or atomic energy by explosion and/or release Air or space travel; this does not apply if a person is a passenger, with no duties at all, on an aircraft being used only to carry passengers (with or without cargo) Disability No benefits are payable if the disability: Is due to intentionally self-inflicted injury (while sane or insane) Results from you committing, or attempting to commit, a criminal act Is due to insurrection, rebellion or taking part in a riot or civil commotion Is due to war or any act of war (declared or not declared) Is not a non-occupational disease (STD only) Is not a non-occupational injury (STD only) Results from driving an automobile while intoxicated ( Intoxicated means: the blood alcohol level of the driver of the automobile meets or exceeds the level at which intoxication would be presumed under the law of the state where the accident occurred.) On any day during a period of disability that a person is confined in a penal or correctional institution for conviction of a criminal or other public offense, the person will not be deemed to be disabled and no benefits will be payable. No benefit is payable for any disability that occurs during the first 12 months of coverage and is due to a pre-existing condition for which the member was diagnosed, treated or received services, treatment, drugs or medicines three (3) months prior to coverage effective date. * These do not apply if the loss is caused by an infection that results directly from the injury or surgery needed because of the injury. The injury must not be one that is excluded by the terms of the contract. MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 47

50 Georgia plan GUIDE Group enrollment checklist Send all enrollment materials directly to Aetna at the address listed below: Aetna Small Business Underwriting F Great Oaks Way Alpharetta, GA Name of Business: Plan Name: Agent/Broker Name: We want to process your request as quickly as possible. You can help by submitting all the necessary paperwork listed below: Employer/Company Application. Employee Enrollment Applications for every employee. Employees waiving coverage must complete the Declination/Waiver of coverage section. Proof of other coverage is needed only for the percentage needed to meet participation. The initial premium check should be in the amount of the first month s premium and drawn on the company check or processed via an Electronic Funds Transfer. Initial Premium Payment payable to Aetna Health Management LLC. Copy of initial quote and census. Copy of medical prescreen evaluation (if applicable). Copy of prior carrier bill roster if replacing coverage. A current copy of one of the following forms for all groups of 2-9 and for groups of 10-plus without prior coverage: DOL-4 form Partnerships must provide a IRS Form 1065 AND Schedule K-1; or IRS Form 1120S Schedule K-1 along with Schedule E (Form 1040) Form 941 and payroll summary Cut off submission dates Applications for groups with: 2-3 eligible employees must be received by Aetna 15 calendar days prior to the requested effective date eligible employees must be received by Aetna 5 business days prior to the requested effective date. Any missing information will result in the effective date being moved forward to the next available date. This checklist may not be all inclusive. Refer to the underwriting guidelines. 48

51 NOTES MEDICAL / PHARMACY DENTAL LIFE / DISABILITY UNDERWRITING 49

52 Aetna Avenue Your Destination for Small Business Solutions This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health/Dental benefits, health/dental insurance, life and disability insurance or benefits plans/policies contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Investment services are independently offered through HealthEquity, Inc. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Plan for Your Health is a public education program from Aetna and The Financial Planning Association. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health, dental and disability services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. The Aetna Personal Health Record should not be used as the sole source of information about the member s medical history. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to GA C (8/11) 2011 Aetna Inc.