NEW JERSEY Aetna Individual Choice Indemnity Plans

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1 NEW JERSEY Aetna Individual Choice Indemnity Plans Thank you for your interest in Aetna Life Insurance Company. In response to your request, we have enclosed information on Aetna s Individual Choice Indemnity Plans. Aetna offers several Individual Choice Indemnity Plans that include, among other services, specialty care, hospitalization for covered services and emergency care. The Individual Choice Indemnity Plans are underwritten by Aetna Life Insurance Company. As a member of one of Aetna s Individual Choice Indemnity Plans, you will have the flexibility to see any recognized physician you wish for covered expenses. Please take a moment to review the enclosed general information about the plans. Here s How to Apply Review the enclosed Policy Application/Enrollment Form carefully, including the back of the form. Review the enclosed Disclosure Statement. Choose a plan. Fill out the entire Policy Application/Enrollment Form. Be sure to answer all questions completely. Sign the Application/Enrollment Form and date it. Make your check payable to Aetna. Please refer to attached Monthly Premium Rate Schedule. Be sure to remit the correct premium payment with your Application/Enrollment Form. Mail your Application/Enrollment Form along with the first monthly premium payment to Aetna. Retain a copy of the Application/Enrollment Form. After your Application/Enrollment Form and payment have been processed, your policy, identification card and claim forms will be mailed to you separately. Please return your Application/Enrollment Form and check for first month s premium to: Aetna Life Insurance Company P.O. Box 2117 Fall River, MA If you have any further questions, please do not hesitate to call us: , Monday through Friday, 8:00 a.m. to 5:00 p.m. Translation of this material into another language may be available. For assistance, please call Member Services at /TDD Puede estar disponible la traducción de este material en otro idioma. Por favor, para ayuda Ilame a Servicios al Miembro al /TDD While this information is believed to be accurate as of the print date, it is subject to change NJ (12/03) 2004 Aetna Inc.

2 NEW JERSEY Aetna Life Insurance Company Summary of Benefits Individual Choice Indemnity Plans PLAN FEATURES Individual Choice Plan A/50 Individual Choice Plan B Individual Choice Plan C Individual Choice Plan D Deductible (per calendar year) Coinsurance Limit PHYSICIAN SERVICES Preventive Care Routine Physical Exams Periodic Physical Assessment Well Baby Care Routine Gynecological Care Nicotine Dependence Treatment Immunizations & Lead Screenings for Children (if not covered under Preventive Care Benefit due to reaching maximum benefit payable) Physician Visits for Injury or Sickness Diagnostic X-Ray/Lab Emergency Room INPATIENT (HOSPITAL) Benefit Deductible/Copay Coinsurance Surgery Physician Hospital Services Outpatient & Ambulatory Surgery OTHER COVERED SERVICES Skilled Nursing Facility (prior approval) Home Health Care (prior approval) $1,000/$2,500 Individual $2,000/$5,000 Family $5,000 individual maximum $10,000 family maximum $300 covered person/year $500 newborn not subject to coinsurance & 50% coinsurance, no $50 copay credited if admitted within 24 hours Coverage limited to 365 days 120 days/year 365 days/year $1,000/$2,500 Individual $2,000/$5,000 Family $3,000 individual maximum $6,000 family maximum $300 covered person/year $500 newborn not subject to coinsurance & 40% coinsurance, no $50 copay credited if admitted within 24 hours Coverage limited to 365 days $200 per day. $1,000 maximum per period of confinement. $2,000 maximum per calendar year. 120 days/year 365 days/year $1,000/$2,500 Individual $2,000/$5,000 Family $2,500 individual maximum $5,000 family maximum $300 covered person/year $500 newborn not subject to coinsurance & 30% coinsurance, no $50 copay credited if admitted within 24 hours Coverage limited to 365 days 120 days/year $500/$1,000 Individual $1,000/$2,000 Family $2,000 individual maximum $4,000 family maximum $300 covered person/year $500 newborn not subject to coinsurance & 20% coinsurance, no $50 copay credited if admitted within 24 hours Coverage limited to 365 days 120 days/year NJ (12/03)

3 PLAN FEATURES Individual Choice Plan A/50 Individual Choice Plan B Individual Choice Plan C Individual Choice Plan D Hospice (prior approval) Inpatient Coverage Outpatient Coverage Durable Medical Equipment Prescription Drugs (includes contraceptive drugs) Rehabilitation Center (acute condition only) Physical Therapy Occupational Therapy Speech Therapy Cognitive Rehabilitation Therapy Therapeutic Manipulation Nutritional Counseling (prior approval) Dental Care and Treatment (for a covered person who is severely disabled or who is a child under 6). Includes general anesthesia and hospitalization for dental services; and dental services rendered by a dentist regardless of where the dental services are provided for a medical condition covered by the policy which requires hospitalization or general anesthesia. Food and Food Products for Inherited Metabolic Diseases MENTAL ILLNESS (Including Alcohol & Substance Abuse) Inpatient Deductible/Copay (Treatment of alcoholism and biologically-based mental illness covered same as any other illness.) Inpatient/Outpatient Coinsurance (Does not apply to overall Plan Coinsurance Limit.) (Treatment of alcoholism and biologicallybased mental illness covered same as any other illness.) Calendar Year Maximum Inpatient/Outpatient Combined (Does not apply to treatment of alcoholism or biologicallybased mental illness) Lifetime Maximum Inpatient/Outpatient Combined (Does not apply to treatment of alcoholism or biologically-based mental illness) Lifetime Maximum Benefit Cap 30 visits/year 30 visits/year 30 visits/year 30 visits/year 30 visits/year $5,000 $25,000 Unlimited 30 visits/year 30 visits/year 30 visits/year 30 visits/year 30 visits/year $200 per day. $1,000 maximum per period of confinement. $2,000 maximum per calendar year. $5,000 $25,000 Unlimited 30 visits/year 30 visits/year 30 visits/year 30 visits/year 30 visits/year $5,000 $25,000 Unlimited 30 visits/year 30 visits/year 30 visits/year 30 visits/year 30 visits/year 25% coinsurance after $5,000 $25,000 Unlimited

4 Pre-Existing Conditions and Limitations For a period of twelve (12) months following the date that an individual files a substantially complete application for coverage and before the first day of coverage, coverage is excluded for any service obtained by or on behalf of a member for conditions of the member (whether physical or mental), regardless of the cause of the condition for which medical advice, diagnosis, care or treatment was recommended or received, during the six (6) months immediately preceding the enrollment date. However, any time the member was previously covered under a previous health insurance plan or policy, health maintenance plan or employer-provided health benefit arrangement, if the previous coverage was continuous to a date of coverage, it shall be credited to the member. The pre-existing condition limitation will not apply if you are an eligible individual under the Health Insurance Portability and Accountability Act (HIPAA) (see section 2741[b] of the Federal Public Health Services Act). Refer to your plan documents for more information. See your plan documents for a complete list of exclusions. What s Not Covered Services and supplies not covered include, but are not limited to, the following: Pre-existing conditions as described to the left Cosmetic surgery Custodial care Hearing aids Experimental or ineffective procedures or treatments Routine foot care Infertility services (except surgical and medical care for diagnosis and treatment of correctable medical conditions otherwise covered by this contract) including, but not limited to, in vitro fertilization procedures, Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), similar and related services Dental care or treatment or X-rays Treatment of mental retardation Reduction of nails, calluses or corns Rehabilitation therapies (including, but not limited to, occupational, speech and cardiac therapy) except for physical therapy Nutritional counseling Foods and Food products for metabolic diseases Skilled nursing facility Home health care Hospice care Durable medical equipment Prescription drugs Translation of this material into another language may be available. For assistance, please call Member Services at /TDD Puede estar disponible la traducción de este material en otro idioma. Por favor, para ayuda Ilame a Servicios al Miembro al /TDD Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies that offer, underwrite or administer benefit coverage include Aetna Life Insurance Company. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e., Individual Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. With the exception of Aetna Rx Home Delivery, all providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. Some benefits are subject to limitations or visit maximums. While this information is believed to be accurate as of the print date, it is subject to change. Plans are offered, underwritten or administered by Aetna Life Insurance Company NJ (12/03) 2004 Aetna Inc.

5 Important Disclosure Information Traditional Choice, indemnity plan members. Plan of Benefits Your plan of benefits will be determined by your plan sponsor and underwritten or administered by the Aetna Life Insurance Company, 151 Farmington Avenue, Hartford, Connecticut, The benefits and main points of the Group Policy for persons covered under your plan of benefits will be set forth in the Booklet-certificate or Booklet which will be provided to you at a later date. Warning: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family. Member Cost Sharing You are responsible for any copayments, coinsurance and s for covered services. These obligations are paid directly to the provider or facility at the time service is rendered. Copayments, coinsurance and amounts are listed in your plan design or benefits summary. Patient Management Program Aetna evaluates and determines the appropriateness of medical care resources utilized by our members. To accomplish these goals, Aetna has developed a comprehensive Patient Management Program. The population demographics of the membership and the program's results are reviewed to determine the need for changes. Regional medical directors in concert with local market medical directors review this information to initiate new program development or enhancement to current programs. The Patient Management Program is reviewed annually. Certification You must obtain certification for certain types of care to avoid a reduction in benefits paid for that care. To request certification, you must call the number shown on your ID card. Certification must be obtained before care is received, or in the case of an emergency admission, procedure or treatment, within 48 hours after the start of a confinement as a full-time inpatient or the performance of the procedure or treatment, or as soon as reasonably possible. Concurrent Review The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review. Discharge Planning Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by the member upon discharge from an inpatient stay. Retrospective Record Review The purpose of retrospective review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions. Aetna's effort to manage the services provided to members includes the retrospective review of claims submitted for payment, and medical records submitted for potential quality and utilization concerns. Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial letters delineate any unmet criteria standards and guidelines, and inform the provider and member of the appeal process (5/03) 1

6 Behavioral Health Certain behavioral health care services (e.g., treatment or care for mental disease or illness, alcohol abuse and/or substance abuse) may be managed by an independently contracted organization. This organization makes initial coverage determinations and coordinates referrals; any behavioral health care referrals will generally be made to providers affiliated with the organization, unless your needs for covered services extend beyond the capability of these providers. You can receive information regarding the appropriate way to access the behavioral health care services that are covered under your specific plan by calling the toll-free number on your I.D. card. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the terms of your health plan. Claim Payment and Use of Claim Software Aetna determines the usual, customary and reasonable fee for a provider by referring to commercially available data reflecting the customary amount paid to most providers for a given service in that geographic area. If such data is not commercially available, our determination may be based upon our own data. Aetna may also use computer software (including ClaimCheck) and other tools to take into account factors such as the complexity, amount of time needed and the manner of billing. You are responsible for any charges Aetna determines are not covered under your plan. Prescription Drugs If your plan covers outpatient prescription drugs, your plan may include a drug formulary. A formulary is a list of prescription drugs generally covered under your prescription drug benefits plan subject to applicable limitations and conditions. The medications listed on the formulary are subject to change in accordance with applicable state law. In evaluating clinically and therapeutically similar drugs for selection for the formulary, Aetna reviews the costs of drugs and takes into account rebates negotiated between Aetna and drug manufacturers. Consequently, a drug may be included on the formulary that is more expensive than a non-formulary alternative before any rebates Aetna may receive from a drug manufacturer are taken into account. In addition, certain drugs may be chosen for formulary status because of their clinical or therapeutic advantages or level of acceptance among physicians even though they cost more than non-formulary alternatives. The net cost to a self-funded plan sponsor for covered prescriptions will vary based on (i) the terms of Aetna's arrangements with participating pharmacies; (ii) the amount of the member's copayment, coinsurance or obligation under the terms of the plan; and (iii) the percentage, if any, of rebates to which the plan sponsor is entitled under its agreement with Aetna. As a result, a self-funded plan sponsor's actual claim expense per prescription for a particular formulary drug may in some circumstances be higher than for a non-formulary alternative. For additional information regarding how medications are reviewed and selected for the formulary, please refer to the Aetna Medication Formulary Guide. A printed copy of the Formulary Guide will be provided, upon request or if applicable, annually for current members and upon enrollment for new members. Additional copies can be obtained by calling Member Services at the toll-free number listed on your member ID card and current Formulary Guide information is available by accessing our website at. Many drugs listed on the formulary are subject to manufacturer rebate arrangements between Aetna and the manufacturer of the drugs. Your pharmacy benefit is not limited to the drugs listed on the formulary. Medications that are not listed on the formulary may be covered subject to the limits and exclusions set forth in your plan documents. Covered prescription drugs not listed on the formulary may be subject to higher copayments under some benefit plans. In prescription plans with copayment or coinsurance tiers, use of formulary drugs generally will result in lower costs to members. However, where the prescription plan utilizes copayments or coinsurance calculated on a percentage basis, there could be some circumstances in which a formulary drug would cost the member more than a non-formulary drug because (i) the negotiated pharmacy payment rate for the formulary drug may be more than the negotiated pharmacy payment rate for the non-formulary drug, and (ii) rebates received by Aetna from drug manufacturers are not reflected in the cost of a prescription drug obtained by a member. Some pharmacy benefit plans may exclude certain drugs not listed on the formulary from coverage. If it is medically necessary for members enrolled in these benefit plans to use such drugs, their physicians (or pharmacist in the case of antibiotics and analgesics) may contact Aetna to request coverage as a medical exception. You may be required to pay the difference in cost between a covered brand-name drug and its generic equivalent in addition to your copayment, depending on the benefit plan selected by your plan sponsor. Check your plan documents for details. In addition, certain drugs may require precertification or step therapy under some prescription drug benefit plans. Step therapy is a different form of precertification which requires a trial of one or more "prerequisite therapy" medications before a "step therapy" medication will be covered. If it is medically necessary for a member to use a medication subject to these requirements, the member's physician can request coverage of such drug as a medical exception. Members should consult with their treating physicians regarding questions about specific medications. Refer to your plan documents or contact Member Services for information regarding the terms and conditions of coverage. 2

7 If you use the mail order prescription services provided by Aetna Rx Home Delivery, you will be acquiring these prescriptions through an affiliate of Aetna. Complaint and Appeals Procedure Our complaints and appeals process is designed to address member coverage issues, complaints and problems. If you have a coverage issue or other problem, call the Member Services toll-free number on your ID card. You can also contact Member Services at for more information. A representative will address your concern. If you are dissatisfied with the outcome of your initial contact, you may appeal the decision. Your appeal will be decided in accordance with the procedures applicable to your plan and applicable state law. Refer to your plan documents for details regarding your plan's complaint and appeals procedures. Confidentiality Aetna considers personal information to be confidential and has policies and procedures in place to protect it against unlawful use and disclosure. By "personal information," we mean information that relates to a member's physical or mental health or condition, the provision of health care to the member, or payment for the provision of health care to the member. Personal information does not include publicly available information or information that is available or reported in a summarized or aggregate fashion but does not identify the member. Some of the ways in which personal information is used include claims payment; utilization review and management; medical necessity reviews; coordination of care and benefits; preventive health, early detection, and disease and case management; quality assessment and improvement activities; auditing and anti-fraud activities; performance measurement and outcomes assessment; health claims analysis and reporting; health services research; data and information systems management; compliance with legal and regulatory requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our business. We consider these activities key for the operation of our health plans. To the extent permitted by law, we use and disclose personal information as provided above without member consent. However, we recognize that many members do not want to receive unsolicited marketing materials unrelated to their health benefits. We do not disclose personal information for these marketing purposes unless the member consents. We also have policies addressing circumstances in which members are unable to give consent. To obtain a copy of our Notice of Privacy Practices, which describes in greater detail our practices concerning use and disclosure of personal information, please call the toll-free Member Services number on your ID card or visit our Internet site at. When necessary or appropriate for your care or treatment, the operation of our health plans, or other related activities, we use personal information internally, share it with our affiliates, and disclose it to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers), payors (health care provider organizations, employers who sponsor self-funded health plans or who share responsibility for the payment of benefits, and others who may be financially responsible for payment for the services or benefits you receive under your plan), other insurers, third party administrators, vendors, consultants, government authorities, and their respective agents. These parties are required to keep personal information confidential as provided by applicable law. Participating network providers are also required to give you access to your medical records within a reasonable amount of time after you make a request. 3

8 Other Disclosures Note: Some states require additional disclosures as follows. This information may not apply to employer-funded plans. Contact Member Services with specific questions about your coverage. Louisiana Aetna will not in any way use the results of genetic testing to discriminate against applicants or enrollees. Michigan Intractable Pain Coverage Aetna provides benefits for the evaluation and treatment of intractable pain when it is determined to be medically necessary and otherwise eligible by Aetna. Intractable pain means "a pain state in which the cause of the pain cannot be removed or otherwise treated and which, in the generally accepted practice of allopathic or osteopathic medicine, no relief of the cause of the pain or cure of the cause of the pain is possible or none has been found after reasonable efforts, including, but not limited to, evaluation by the attending physician and by one or more other physicians specializing in the treatment of the area, system, or organ of the body perceived as the source of the pain." Notice to Members While this information is believed to be accurate as of the print date, it is subject to change. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Consult the plan documents [Booklet, Booklet-certificate] to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. The availability of a plan or program may vary by geographic service area. Some benefits are subject to limitations or visit maximums. "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. 4

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