PLAN DESIGN AND BENEFITS - PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) 51+ $1,000 Individual $2,000 Family

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1 Aetn Helth Insurnce Compny (Non-Prticipting) PLAN FEATURES Deductible (per clendr yer) Lifetime Mximum Pyment for services from Non-Prticipting Provider Primry Cre Physicin Selection Unlimited Not Applicble Required Unlimited Professionl: 105% of Medicre* Fcility: 140% of Medicre* Not Applicble Precertifiction Requirement - Certin non-prticipting provider services require precertifiction or benefits will be reduced. Refer to your pln documents for complete list of services tht require precertifiction. Referrl Requirement PHYSICIAN SERVICES Primry Cre Physicin Visits Specilist Office Visits Pre-Ntl Mternity Mternity - Delivery nd Post-Prtum Cre Allergy Tretment Allergy Testing PREVENTIVE CARE Routine Adult Physicl Exms/ Immuniztions (Limited to one exm every 12 months. Prticipting nd Non-Prticipting PARTICIPATING PROVIDERS $1,000 Individul $2,000 Fmily NON-PARTICIPATING PROVIDERS $5,000 Individul $10,000 Fmily Unless otherwise indicted, the Deductible must be met prior to benefits being pyble. All covered expenses ccumulte seprtely towrd the prticipting nd non-prticipting Deductible. Once the Fmily Deductible is met, ll fmily members will be considered s hving met their Deductible for the reminder of the clendr yer. No one fmily member my contribute more thn the Individul Deductible mount to the Fmily Deductible. Deductible credit pplies. Deductible crryover does not pply. Member Coinsurnce Not Applicble 50% Out-of-Pocket Mximum $3,000 Individul $10,000 Individul (per clendr yer, includes deductible) $6,000 Fmily $20,000 Fmily Amounts over the Recognized Chrge, filure to pre-certifiction penlties nd member cost-shring for prescription drug benefits do not pply towrd the Out-of-Pocket Mximum. All covered expenses ccumulte seprtely towrd the prticipting nd non-prticipting Out-of-Pocket Mximum. Once the Fmily Out-of-Pocket Mximum is met, ll fmily members will be considered s hving met their Out-of-Pocket Mximum for the reminder of the clendr yer. No one fmily member my contribute more thn the Individul Out-of-Pocket Mximum mount to the Fmily Out-of-Pocket Mximum. Required for ll non-emergency, Not Applicble non-urgent nd non-primry Cre Physicin services, except direct ccess services. Office Hours: $25 Copy, deductible wived After Office Hours/Home: $30 Copy, deductible wived $50 Copy, deductible wived $0 Copy, deductible wived $50 Copy, deductible wived Sme s pplicble prticipting provider office visit member cost shring. $50 Copy, deductible wived $0 Copy, deductible wived 50%, deductible wived PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) Pln Effective 8/12 - V1 Pge 1

2 Aetn Helth Insurnce Compny (Non-Prticipting) PREVENTIVE CARE (CONTINUED) Well Child Exms/Immuniztions $0 Copy, deductible wived 50%, deductible wived (Limited to 7 exms in the first 12 months of life; 3 exms in the second 12 months of life; 3 exms in the third 12 months of life; 1 exm per 12 months therefter. Prticipting nd Non-Prticipting Routine Gynecologicl Exms $0 Copy, deductible wived 50%, deductible wived (Limited to one routine exm nd pp smer per 365 dys. Prticipting nd Non-Prticipting Routine Mmmogrms $0 Copy, deductible wived (Recommended: One nnul mmmogrm for covered femles ge 40 nd over. Prticipting nd Non-Prticipting Women's Helth (Includes: Screening for gesttionl dibetes; HPV (Humn Ppillomvirus) DNA testing; counseling for sexully trnsmitted infections; counseling nd screening for humn immunodeficiency virus; screening nd counseling for interpersonl nd domestic violence; brestfeeding support, supplies nd counseling; nd contrceptive methods nd counseling. Limittions my pply.) Routine Digitl Rectl Exms/Prostte Specific Antigen Test (Recommended for covered mles ge 40 nd over. Age nd frequency schedules my pply. Prticipting nd Non-Prticipting Colorectl Cncer Screening (For ll members ge 50 nd over. Frequency schedule pplies. Prticipting nd Non-Prticipting Routine Eye Exms t Specilist (Limited to one routine exm per 24 months. Prticipting nd Non-Prticipting $0 Copy, deductible wived Member cost shring is bsed on $0 Copy, deductible wived Member cost shring is bsed on $0 Copy, deductible wived Member cost shring is bsed on $0 Copy, deductible wived Routine Hering Screening t PCP Covered only s prt of physicl exm. Subject to Routine Physicl Exm cost shring. Subject to Routine Physicl Exm cost shring. PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) Pln Effective 8/12 - V1 Pge 2

3 Aetn Helth Insurnce Compny (Non-Prticipting) DIAGNOSTIC PROCEDURES Dignostic Lbortory $0 Copy, deductible wived (If performed s prt of physicin's office visit nd billed by the physicin, expenses re covered subject to the pplicble physicin's office visit cost shring.) Dignostic X-ry (except for Complex $50 Copy, deductible wived Imging Services) - Outptient Hospitl or Other Outptient Fcility Dignostic X-ry for Complex Imging $200 Copy, deductible wived Services (Includes MRA/MRS, MRI, PET nd CAT Scns) EMERGENCY MEDICAL CARE Urgent Cre Provider $50 Copy, deductible wived Non-Urgent use of Urgent Cre Provider Emergency Room $200 Copy, deductible wived Refer to prticipting provider benefit. (Copy wived if dmitted.) Non-Emergency cre in n Emergency Room Emergency Ambulnce $0 Copy, deductible wived Refer to prticipting provider benefit. Non-Emergency Ambulnce HOSPITAL CARE Inptient Coverge (Including mternity nd trnsplnts) fter deductible (Trnsplnts: Coverge, provided t n IOE contrcted fcility, is subject to Prticipting cost-shring. Coverge provided t non-ioe contrcted fcility, is subject to Non-Prticipting cost-shring.) Outptient Surgery $0 Copy fter deductible (Provided in n outptient hospitl deprtment or freestnding surgicl fcility.) MENTAL HEALTH SERVICES Inptient Serious Mentl Illness fter deductible Outptient Serious Mentl Illness Inptient Non-Serious Mentl Illness Outptient Non-Serious Mentl Illness ALCOHOL/DRUG ABUSE SERVICES Inptient Detoxifiction Outptient Detoxifiction Inptient Rehbilittion Outptient Rehbilittion Residentil Tretment Fcility $50 Copy, deductible wived fter deductible $50 Copy, deductible wived fter deductible $50 Copy, deductible wived fter deductible $50 Copy, deductible wived fter deductible PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) Pln Effective 8/12 - V1 Pge 3

4 Aetn Helth Insurnce Compny (Non-Prticipting) OTHER SERVICES Skilled Nursing Fcility (Limited to 120 dys per member per clendr fter deductible yer. Prticipting nd Non-Prticipting Home Helth Cre $50 Copy, deductible wived (Limited to 60 visits per member per clendr yer, no more thn 3 intermittent visits per dy by Home Helth Cre gency, 1 visit equls period of 4 hours or less. Prticipting nd Non-Prticipting Infusion Therpy (Provided in the home or physicin's office) Infusion Therpy (Provided in n outptient hospitl deprtment or freestnding fcility.) Hospice Cre - Inptient Hospice Cre - Outptient Outptient Physicl nd Occuptionl Therpy (Physicl nd Occuptionl Therpy limited to 30 visits [combined] per member per clendr yer. Prticipting nd Non-Prticipting Outptient Speech Therpy (Limited to 30 visits per member per clendr yer. Prticipting nd Non-Prticipting Subluxtion (Chiroprctic) (Limited to 20 visits per member per clendr yer. Prticipting nd Non-Prticipting $50 Copy, deductible wived $0 Copy fter deductible fter deductible $0 Copy, deductible wived $50 Copy, deductible wived $50 Copy, deductible wived $10 Copy, deductible wived 25% fter deductible PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) Pln Effective 8/12 - V1 Pge 4

5 Aetn Helth Insurnce Compny (Non-Prticipting) OTHER SERVICES (CONTINUED) Tretment of Autism (Plns issued or renewed prior to 1/1/13: Covered the sme s ny other expense. Limited to $36,000 nnully for eligible individuls under 21 yers of ge. Includes coverge for hbilittive cre nd Applied Behviorl Anlysis. Once the limit hs been met, Applied Behviorl Anlysis will be covered under Mentl Helth services. Plns issued or renewed on nd fter 1/1/13: Covered the sme s ny other expense. Limited to $37,080 nnully for eligible individuls under 21 yers of ge. Includes coverge for hbilittive cre nd Applied Behviorl Anlysis. Once the limit hs been met, Applied Behviorl Anlysis will be covered under Mentl Helth services.) Member cost shring is bsed on Member cost shring is bsed on Vision Corrective Lenses/ Contct Lenses Allownce Durble Medicl Equipment (Mximum benefit of $2,500 per member per clendr yer. Prticipting nd Non-Prticipting FAMILY PLANNING Infertility Tretment (Coverge for only the dignosis nd surgicl tretment of the underlying medicl cuse.) Comprehensive Infertility Services Advnced Reproductive Technology (ART) (Includes In-Vitro Fertiliztion (IVF), Zygote Intr-Fllopin Trnsfer (ZIFT), Gmete Intr- Fllopin Trnsfer (GIFT), cryopreserved embryo trnsfers, Intr-Cytoplsmic Sperm Injection (ICSI) or ovum microsurgery.) Vsectomy Tubl Ligtion $100 reimbursement pyble once for 24-month period 50%, deductible wived PARTICIPATING PROVIDERS Member cost shring is bsed on Member cost shring is bsed on $0 Copy, deductible wived Refer to prticipting provider benefit. (Must pre-certify if over $1,500.) NON-PARTICIPATING PROVIDERS Member cost shring is bsed on PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) Pln Effective 8/12 - V1 Pge 5

6 Aetn Helth Insurnce Compny (Non-Prticipting) PHARMACY- PRESCRIPTION DRUG BENEFITS Prescription Drug Deductible Prescription Drugs Up to 30-dy supply Prescription Drugs (Retil or Mil Order) dy supply PARTICIPATING PHARMACIES Specilty Cre Drugs (Self-injectble, infused nd orl specilty drugs) Not Applicble $15 Copy for generic formulry drugs, $45 Copy for brnd-nme formulry drugs, nd $75 Copy for generic nd brnd-nme non-formulry drugs $30 Copy for generic formulry drugs, $90 Copy for brnd-nme formulry drugs, nd $150 Copy for generic nd brnd-nme non-formulry drugs $250 copy for formulry nd non-formulry drugs Aetn Specilty CreRx SM - First Prescription for specilty drug must be filled t prticipting retil phrmcy or Aetn Specilty Phrmcy. Subsequent fills must be through Aetn Specilty Phrmcy. No Mndtory Generic (No MG) - Member is responsible to py the pplicble copy or coinsurnce. Pln includes dibetic supplies, orl fertility drugs, contrceptive drugs nd devices obtinble from phrmcy. Formulry generic FDA-pproved Women s Contrceptives, certin brnd formulry contrceptives when pproved, femle condoms, spermicides, sponges nd emergency contrception covered 100% in network. Precertifiction nd step-therpy included. 90 dy Trnsition of Cre (TOC) for Precertifiction nd Step Therpy included. NON-PARTICIPATING PHARMACIES Not Applicble * We cover the cost of services bsed on whether doctors re in network or out of network. We wnt to help you understnd how much Aetn pys for your out-of-network cre. At the sme time, we wnt to mke it cler how much more you will need to py for this "out-of-network" cre. You my choose provider (doctor or hospitl) in our network. You my choose to visit n out-of-network provider. If you choose doctor who is out of network, your Aetn helth pln my py some of tht doctor's bill. Most of the time, you will py lot more money out of your own pocket if you choose to use n out-of-network doctor or hospitl. When you choose out-of-network cre, Aetn limits the mount it will py. This limit is clled the recognized or llowed mount. When you choose out-of-network cre, Aetn recognizes n mount bsed on wht Medicre pys for these services. The government sets the Medicre rte. Your doctor sets his or her own rte to chrge you. It my be higher -- sometimes much higher -- thn wht your Aetn pln "recognizes." Your doctor my bill you for the dollr mount tht Aetn doesn't "recognize." You must lso py ny copyments, coinsurnce nd deductibles under your pln. No dollr mount bove the "recognized chrge" counts towrd your deductible or out-of-pocket mximums. To lern more bout how we py out-of-network benefits visit Aetn.com. Type "how Aetn pys" in the serch box. You cn void these extr costs by getting your cre from Aetn's brod network of helth cre providers. Go to nd click on "Find Doctor" on the left side of the pge. If you re lredy member, sign on to your Aetn Nvigtor member site. PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) Pln Effective 8/12 - V1 Pge 6

7 Aetn Helth Insurnce Compny (Non-Prticipting) This pplies when you choose to get cre out of network. When you hve no choice (for exmple: emergency room visit fter cr ccident, or for other emergency services), we will py the bill s if you got cre in network. You py cost shring nd deductibles for your in-network level of benefits. Contct Aetn if your provider sks you to py more. You re not responsible for ny outstnding blnce billed by your providers for emergency services beyond your cost shring nd deductibles. Wht's This pln does not cover ll helth cre expenses nd includes exclusions nd limittions. Refer to your pln documents to determine which helth cre services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln documents my contin exceptions to this list bsed on stte mndtes or the pln design or rider(s) purchsed. (1) All medicl or hospitl services not specificlly covered in, or which re limited or excluded by your pln documents, including costs of services before coverge begins nd fter coverge termintes. (2) Cosmetic surgery, including brest reduction. (3) Custodil cre. (4) Dentl cre nd x-rys. (5) Donor egg retrievl. (6) Experimentl nd investigtionl procedures (except for coverge for mediclly necessry routine ptient cre costs for Members prticipting in cncer clinicl tril). (7) Hering ids. (8) Home births. (9) Immuniztions for trvel or work. (10) Implntble drugs nd certin injectble drugs, including injectble infertility drugs. (11) Infertility services including rtificil insemintion nd dvnced reproductive technologies such s IVF, ZIFT, GIFT, ICSI nd other relted services unless specificlly listed s covered in your pln documents. (12) Non-mediclly necessry services or supplies. (13) Orthotics, except dibetic orthotics. (14) Over-the-counter medictions (except s provided in hospitl) nd supplies. (15) Rdil kertotomy or relted procedures. (16) Reversl of steriliztion. (17) Services for the tretment of sexul dysfunction or indequcies, including therpy, supplies, counseling nd prescription drugs. (18) Specil duty nursing. (19) Therpy or rehbilittion other thn those listed s covered in the pln documents. (20) Weight control services including surgicl procedures, medicl tretments, weight control/loss progrms, dietry regimens nd supplements, ppetite suppressnts nd other medictions; food or food supplements, exercise progrms, exercise or other equipment; nd other services nd supplies tht re primrily intended to control weight or tret obesity, including Morbid Obesity, or for the purpose of weight reduction, regrdless of the existence of comorbid conditions. PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) Pln Effective 8/12 - V1 Pge 7

8 Aetn Helth Insurnce Compny (Non-Prticipting) This mnged cre pln my not cover ll of your helth cre expenses. Red your contrct crefully to determine which helth cre services re covered. To contct the pln if you re member, cll the number on your ID crd. Groups of 2-50 Eligible Employees: All others, for HMO nd QPOS products cll: AETNA ( ). For Helth Network Option products cll: For Trditionl/PPO products cll: AETNA ( ). Groups of Eligible Employees: All others, for HMO nd QPOS products cll: For Helth Network Option products cll: For Trditionl/PPO products cll: This mteril is for informtionl purposes only nd is not n offer or invittion to contrct. An ppliction must be completed to obtin coverge. Rtes nd benefits my vry by loction. Helth benefits nd helth insurnce plns contin exclusions nd limittions. Not ll helth services re covered. You my be responsible for the helth cre provider's full chrges for ny non-covered services, including circumstnces where you hve exceeded benefit limit contined in the pln. See pln documents for complete description of benefits, exclusions, limittions nd conditions of coverge. Pln fetures nd vilbility my vry by loction nd group size. Pln fetures re subject to chnge. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to helth services. If you re in pln tht requires the selection of primry cre physicin nd your primry cre physicin is prt of n integrted delivery system or physicin group, your primry cre physicin will generlly refer you to specilists nd hospitls tht re ffilited with the delivery system or physicin group. In cse of emergency, cll 911 or your locl emergency hotline, or go directly to n emergency cre fcility. If your pln covers outptient prescription drugs, your pln my include drug formulry (preferred drug list). A formulry is list of prescription drugs generlly covered under your prescription drug benefits pln on preferred bsis subject to pplicble limittions nd conditions. Your phrmcy benefit is generlly not limited to the drugs listed on the formulry. The medictions listed on the formulry re subject to chnge in ccordnce with pplicble stte lw. For informtion regrding how medictions re reviewed nd selected for the formulry, formulry informtion, nd informtion bout other phrmcy progrms, such s, pre-certifiction nd step-therpy, plese refer to Aetn's website t Aetn.com, or the Aetn Mediction Formulry Guide. Aetn receives rebtes from drug mnufcturers tht my be tken into ccount in determining Aetn's Preferred Drug List. Rebtes do not reduce the mount member pys the phrmcy for covered prescriptions. In ddition, in circumstnces where your prescription pln utilizes copyments or coinsurnce clculted on percentge bsis or deductible, use of formulry drugs my not necessrily result in lower costs for the member. Members should consult with their treting physicins regrding questions bout specific medictions. Refer to your pln documents or contct Member Services for informtion regrding the terms nd limittions of coverge. Aetn Rx Home Delivery refers to Aetn Rx Home Delivery, LLC. Aetn Specilty Phrmcy refers to Aetn Specilty Phrmcy, LLC. Both re subsidiries of Aetn Inc. nd re licensed phrmcies tht operte through mil order. The chrges tht Aetn negotites with Aetn Rx Home Delivery nd Aetn Specilty Phrmcy my be higher thn the cost those phrmcies py for the drugs nd the costs of their specilty phrmcy services. For these purposes, Aetn Specilty Phrmcy s nd Aetn Rx Home Delivery s cost of purchsing drugs tkes into ccount discounts, credits nd other mounts tht those phrmcies my receive from wholeslers, mnufcturers, suppliers nd distributors. "Aetn" is the brnd nme used for products nd services provided by one or more of the Aetn group subsidiry compnies. For more informtion bout Aetn plns, refer to While this mteril is believed to be ccurte s of the print dte, it is subject to chnge. PA POS CS 2.7 CY (1000 Ded, 15/45/75 RX) Pln Effective 8/12 - V1 Pge 8