Read Aetna EPO Plan Summary Plan Description text version

Summary Plan Description

Aetna EPO Plan

Effective January 1, 2011

Aetna EPO Plan

Contents

Contacts 1 Chapter 1: Administrative information 3 The basics 3 Who's eligible3 Plan information3 Chapter 2: Aetna EPO Plan 5 How the Plan works 5 The basics 5 How the Plan works 11 Using the Aetna Open Access and Aetna Select Networks12 Health Information Line 14 What the Plan covers 14 What is not covered 27 Claims and appeals30 Coordination with other coverage31 Subrogation and right of recovery provisions 31 Chapter 3: Prescription drug benefit33 The basics 33 What's covered34 Your ID card36 CVS Caremark Specialty Pharmacy 36 Some prescriptions may require prior authorization36 Prescriptions that are not covered38 Out-of-pocket maximums 39 Prescription drug coordination of benefits39 Claims and appeals39 Other things you should know40 Chapter 4: Mental health and substance abuse benefits 41 Aetna Behavioral Health41 Mental Health and Substance Abuse Plan benefits 43 Treatment of mental disorders and substance abuse 43 What is not covered 46 Claims and appeals48

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Contacts

Information about the Aetna EPO Plan Aetna 1-888-802-4271 aetnacom Group Number 476683 Information about Aetna health programs Information about prescription drugs 1-888-802-4271 aetnacom CVS Caremark 1-800-772-2301 caremarkcom Information about mental health or substance abuse Aetna Behavioral Health 1-888-802-4271 wfaetnaplancom Employee Assistance Consulting 1-888-327-0027 For TDD access for persons with hearing impairments, please call 1-877-411-0826 Information about providers in your area Provider Directory Service geoaccesscom/directoriesonline/wf Wells Fargo Medical Plan Comparison Tool wfchooserpbghorg Information about premiums for the Aetna EPO Plan Information on enrollment, eligibility, or making changes Check your enrollment materials, or go to Teamworks Teamworks HR Service Center 1-877-HRWELLS (1-877-479-3557) For TDD access for persons with hearing impairments, please call 1-800-988-0161 [email protected]

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Aetna EPO Plan

Chapter 1

Administrative information

The basics

This Summary Plan Description (SPD) covers the provisions of the Aetna EPO Plan (the Plan) While reading this material, be aware that: · The Plan is a welfare benefits plan provided as a benefit to eligible team members and their eligible dependents Participation in this plan does not constitute a guarantee or contract of employment with Wells Fargo & Company or its subsidiaries Plan benefits depend on continued eligibility · The name "Wells Fargo," as used throughout this document, refers to Wells Fargo & Company In case of any conflict between the SPD, any other information provided, and the official Plan document, the Plan document governs Plan administration and benefits decisions You may request a copy of the official Plan document by submitting a written request to the address below, or you may view the document on-site during regular business hours by prior arrangement: Compensation and Benefits Department Wells Fargo MAC N9311-170 625 Marquette Avenue Minneapolis, MN 55479 Wells Fargo contracts with third-party administrators to provide claims administrative services These third-party administrators are referred to as claims administrators While the Plan's provisions determine what services and supplies are eligible for benefits, you and your health care provider have ultimate responsibility for determining the treatment and care you receive

Definition of a Summary Plan Description (SPD)

An SPD explains your benefits and rights under the Plan The SPD includes this booklet, and the first chapter and the appendixes of your Benefits Book The Benefits Book and SPDs are available on Teamworks at work and at home Every attempt has been made to make the Benefits Book and SPDs easy to understand, informative, and as accurate as possible However, an SPD cannot replace or change any provision of the actual Plan documents As a participant in this Plan, you are entitled to certain rights and protection under the Employee Retirement Income Security Act of 1974 as amended (ERISA) For a list of specific rights, review the section "Your rights under ERISA" in "Appendix B: Legal notifications" of your Benefits Book

Who's eligible

Each team member who satisfies the Plan's eligibility requirements may enroll Your employment classification determines eligibility to participate in this Plan For more information regarding employment classification and eligibility, refer to "Chapter 1: An introduction to your benefits" in your Benefits Book

Plan information

Claims administrator

Aetna is the organization designated by the plan administrator to receive, process, and administer claims for benefits described in Chapter 2 of this SPD and make claim payments for such benefits on behalf of the Plan Aetna is the claims fiduciary for claims for benefits described in Chapter 2 of this SPD CVS Caremark is the organization designated by the plan administrator to receive, process, and administer claims for prescription drug benefits described in Chapter 3 of this SPD and make claim payments for such benefits on behalf of the Plan CVS Caremark is the claims fiduciary for claims for prescription drug benefits described in Chapter 3 of this SPD

Responsibilities of covered persons

Each covered team member and covered dependent is responsible for reading this SPD and related materials completely and complying with all rules and Plan provisions

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Aetna Behavioral Health is the organization designated by the plan administrator to receive, process, and administer claims for mental health and substance abuse benefits described in Chapter 4 of this SPD and make claim payments for such benefits on behalf of the Plan Aetna Behavioral Health is the claims fiduciary for claims for mental health and substance abuse benefits described in Chapter 4 of this SPD Aetna, CVS Caremark, and Aetna Behavioral Health are not the administrators for appeals related to rescission of coverage Wells Fargo Corporate Benefits has the discretionary authority to determine whether medical coverage will be rescinded (retroactively cancelled) Please see "Appendix A: Claims and appeals" in your Benefits Book for more details Contact information for each of the claims administrators is provided below: Aetna Inc 151 Farmington Avenue Hartford, CT 06156

1-888-802-4271

Note: This Aetna claims address is for both medical and mental health and substance abuse claims.

CVS Caremark PO Box 52196 Phoenix, AZ 85072 1-800-772-2301

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Aetna EPO Plan

Chapter 2

Aetna EPO Plan

How the Plan works

This SPD describes your covered services and how to access them The Plan provides Aetna EPO network benefits to receive covered services Most of this SPD contains information you need to know to obtain benefits for covered services Coverage may vary depending on where you receive the services (eg, office or clinic, outpatient facility, outpatient hospital, inpatient hospital) When your provider submits a claim, he or she will inform the Plan of the services you received and where you received them For example, if your provider codes the claim as an office visit, the office visit copay will apply If your provider codes the claim as an outpatient or inpatient facility, coinsurance will apply In addition, if your provider sends you to another facility for lab or imaging services (eg, x-ray, MRI, CT scan) or sends out your lab work to a separate facility, the additional claim may result in a separate coinsurance charge for services received at the facility If you have questions about how your claims will be coded when submitted to the Plan, ask your provider how a service will be coded before he or she submits it to the Plan Once the claim is submitted to the Plan, the claim will be processed based on how your provider coded the claim For example, services coded by your provider as received in an outpatient facility will be subject to the outpatient facility coinsurance (not the office visit copay) Enrolling in the Plan does not guarantee that any particular service, supply, or piece of medical equipment will be covered, even if it is covered at the start of the calendar year before receiving services to receive authorization The Plan pays benefits similar to an HMO, but the Plan is self-insured by Wells Fargo Aetna is the claims administrator for medical claims as well as mental health and substance abuse claims CVS Caremark is claims administrator for prescription drug claims A self-insured plan means that benefits are paid from company and team member contributions Wells Fargo contracts with Aetna to perform administrative services and process claims which, in turn, contracts with hospitals and doctors to create the Aetna Network When you enroll in this Plan, you agree to give your health care providers permission to provide the claims administrator, Aetna, access to required information about the care provided to you The claims administrator may require this information to process claims, conduct utilization review for quality improvement activities, and for other health plan activities, as permitted by law The claims administrator may release the information, if you authorize it to do so, or if state or federal law permits or allows release without your authorization If a provider requires a special authorization for release of records, you agree to provide the authorization Your failure to provide authorization or requested information may result in denial of your claim As always, it is between you and your provider to determine the treatments and procedures that best meet your needs The terms of the Plan control what, if any, benefits are available for the services you receive The fact that a physician has performed or prescribed a procedure or treatment, or the fact that it may be the only treatment for a particular injury, sickness, mental illness, or pregnancy, does not mean that it is a covered health service as defined by the Plan The definition of a covered health service relates only to what is covered by the Plan and may differ from what your physician deems to be a covered health service

The basics

The Aetna EPO Plan (the Plan) is an Open Access Select Plan offered in several locations To receive benefits, you must use Aetna's network of providers under the Open Access Select Plan If you do not use Aetna's Open Access Select Plan network of providers, services are not covered except in emergency situations However, in rare cases, Aetna may provide authorization for you to receive nonemergency services from a nonnetwork provider Contact Aetna

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Your benefits and costs at a glance

These benefits and cost-sharing amounts apply to individuals enrolled in the Plan and are subject to the procedures, exclusions, and limitations in this SPD Benefit features

Annual deductible Annual coinsurance maximum (includes mental health and substance abuse coinsurance; excludes prescriptions and copays) Primary care physician (PCP) requirements Doctor's office visits Maximum visits apply to some service categories, see benefit descriptions for details Preventive care (annual physicals, well-baby visits, immunizations) For qualifying preventive care services, based on annual exam schedule Walk-in clinics Urgent care clinics Durable medical equipment and prosthetics Emergency room As defined under "Emergency care" If you do not meet the Emergency care criteria according to Aetna, you will be responsible for the entire bill Maternity Initial visit to confirm pregnancy Subsequent prenatal and postnatal visits, as part of Global Obstetrics Package Prenatal and postnatal visits outside the Global Obstetric Package Delivery -- hospital inpatient and physician charges Home health care (limit of 100 visits, combined with extended skilled nursing, in a calendar year) Hospice care Hospital care Outpatient surgery, diagnostic, and therapeutic services (including labs and x-rays) Performed in a hospital or an outpatient facility, or performed as part of a physician office visit and the physician sends it out to an independent lab Performed in a physician's office and billed by physician You pay 10% of eligible covered expenses You pay $25 copay You pay 10% of eligible covered expenses You pay $25 copay You pay 10% of eligible covered expenses You pay 10% of eligible covered expenses You pay $10 copay per visit You pay $40 copay per visit You pay 10% of eligible covered expenses You pay $100 copay, then Plan pays 100% of eligible covered expenses (if admitted, copay waived and hospital coinsurance will apply) You pay nothing

Network benefits

None Individual $2,500; family $5,000

You may use any Open Access Select Plan network physician; no referral or PCP designation is required You pay $25 copay per visit

You pay 10% of eligible covered expenses You pay 10% of eligible covered expenses (inpatient care or other care rendered in a hospital setting)

You pay $25 copay

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Benefit features

Prescriptions Administered by CVS Caremark Therapy and chiropractic services Physical, occupational, and speech therapy (90 visits per calendar year, all therapies combined) Chiropractic care (26 visits per calendar year) Acupuncture Maximum of 26 visits per calendar year Skilled nursing care facility (limit of 100 days per calendar year) Vision and hearing Eyewear Hearing screenings Hearing aids

Network benefits

See the "What you'll pay for prescriptions" table on page 35 for coverage information

You pay a $25 copay for each visit You pay a $25 copay for each visit You pay $25 copay

You pay 10% of eligible covered expenses

Not covered Only covered as part of eligible preventive well-child care You pay 10%, covered only through the calendar year in which dependent child turns age 18 Limit of once every three years (this includes one hearing aid or a set of hearing aids)

Family planning (infertility treatment subject to a $10,000 lifetime maximum) Infertility treatment for diagnosis and treatment for correction of underlying conditions, including artificial insemination for diagnosed infertility · Performed in physician's office · Performed in hospital or outpatient facility In vitro fertilization Infertility drugs Other assisted reproductive procedures (including ovulation induction) Mental health and substance abuse · You pay $25 copay per visit · You pay 10% of eligible covered expenses Not covered Not covered Not covered Access through Aetna Behavioral Health

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Aetna programs

Beginning Right® Maternity Program

Overview

The Beginning Right Maternity Program offers services and education materials to help from the start of your pregnancy, up until the baby is born Special program features include: · Educational materials · Education program services through Women's Health Online, a pregnancy risk survey · Special information for dad or partner · Access to obstetrical nurses · Special programs: ­ Smoke-Free Moms-to-Be ­ Breastfeeding support and education ­ Preterm labor education

How to access and enroll

Sign on to the Aetna Navigator® secure website at aetnanavigatorcom or call Member Services at 1-888-802-4271

Disease management programs: Aetna Health ConnectionsSM

Aetna's disease management program coordinates education, counseling, patient self-care, and physician support to help you manage your condition Aetna Health Connections reaches out to Aetna members to provide support for more than 34 common medical conditions If you enroll in the program, you'll receive: · A personal health review by a trained nurse · Ongoing telephone access to disease management professionals · Educational materials · Individualized case management information

You may be identified for program participation through patient management staff or you can sign on to the Aetna Navigator secure website at aetnanavigatorcom You may also call Member Services at 1-888-802-4271

Informed Health® Line

The Informed Health Line gives you access to registered nurses experienced in providing information on a variety of health topics You can call 24 hours a day, 7 days a week to: · Talk to a registered nurse · Listen to Audio Health Library, a recorded collection of more than 2,000 health topics · Access Healthwise® Knowledgebase, a decision-support tool with an advanced health search database to health information resources

Call 1-800-556-1555 or sign on to the Aetna Navigator secure website at aetnanavigatorcom

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Aetna EPO Plan

Aetna programs

Personal Health Record (PHR)

Overview

The Aetna Personal Health Record (PHR) is a comprehensive online record that is prepopulated with health information from Aetna's claims system and gives you the opportunity to enter nonclaims personal health information You can choose to: · Answer questions from the online tutorial (called the Walk Me Through tool) · Complete the online health assessment under Simple Steps To A Healthier Life · Use the tabbed sections within the PHR

How to access and enroll

Sign on to the Aetna Navigator secure website at aetnanavigatorcom to learn more about the program and the additional services; click View Your Personal Health Record on the Aetna Navigator secure website

Simple Steps To A Healthier Life®

The Simple Steps To A Healthier Life program is a convenient and secure online health and wellness program that is personalized to address your health needs at no additional cost This program offers resources to help members eat right, get in shape, lose weight, cope better with stress, and much more The program consists of three steps: · Step 1: Understand your health needs You start by answering some questions in your online Health Assessment · Step 2: Set some goals for yourself Next, you will receive easy-to-understand reports based on the results of your Health Assessment You can use this information to set a few healthy goals for yourself · Step 3: Select the programs and tools that are right for you You'll find content that speaks to your health needs, based on the information you share These programs help you target health and wellness goals

Sign on to the Aetna Navigator secure website at aetnanavigatorcom and select Simple Steps To A Healthier Life

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Aetna programs

Alternative Health Care Programs

Overview

The Alternative Health Care Programs provide alternative choices to members who want to explore new products in the area of alternative medicine Save money as you explore and use a variety of alternative approaches to preventive care and the maintenance of good health The Alternative Health Care Programs are: · Natural Alternatives: Discounts on chiropractic manipulation, acupuncture therapy, massage therapy, and nutritional counseling · Vitamin AdvantageTM: Discounts on retail-price vitamins and herbal and nutritional supplements · Natural Products: Savings on aromatherapy, books, and videos, biomagnetics, yoga equipment, teas, natural body care, and homeopathic products

How to access and enroll

You do not need a referral or prior approval to use the Natural Alternatives program All you have to do is: 1 Confirm that the service you want is available through Natural Alternatives 2 Schedule an appointment (To find a nearby participating Natural Alternatives provider, sign on to the Aetna Navigator secure website at aetnanavigatorcom or call 1-888-802-4271) 3 Pay the discounted fee directly to the provider at the time the service is received No need to file a claim To order products through the Vitamin Advantage program and the Natural Products program, sign on to the Aetna Navigator secure website at aetnanavigatorcom and select DocFind® ­ Alternative Therapy Professionals to view participating retailers and a listing of health-related products Sign on to the Aetna Navigator website at aetnanavigatorcom to learn more about the program

Fitness program

This program is offered in conjunction with GlobalFitTM, a premier fitness benefits company with a large discounted health club network The fitness program gives you access to reduced health club membership rates within the GlobalFit network You can: · View rates online · Try out health clubs before joining · Join clubs month to month · Work out while traveling · Freeze, transfer, or cancel club memberships conveniently · Receive price breaks on certain home exercise equipment

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Aetna EPO Plan

How the Plan works

Covered health services

Health services and supplies provided for the purpose of preventing, diagnosing, or treating a sickness, injury, or their symptoms are considered covered health services as described in the "What the Plan covers" section on page 14 and not included in the "What is not covered" section on page 27 Experimental or investigational services and unproven services are not a covered health service (See the "Experimental or investigational procedure" section on page 27 and the "Unproven services" section on page 28 for more details) Aetna has the discretion to determine what a medically necessary covered health service is based on plan terms and established medical policies used by Aetna To be a medically necessary covered health service, Aetna must determine that the service is medically appropriate and: · Necessary to meet the basic health needs of the participant · Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the service or supply · Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies that are accepted by the utilization review organization or claims administrator · Consistent with the diagnosis of the condition · Required for reasons other than the convenience of the participant or his or her physician · Demonstrated through prevailing peer-reviewed medical literature, as determined by Aetna, to be one of the following: ­ Safe and effective for treating or diagnosing the condition or sickness for which its use is proposed ­ Safe with promising efficacy for treating a life-threatening sickness or condition in a clinically controlled research setting and using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health (Life-threatening is used to describe sicknesses or conditions that are more likely than not to cause death within one year of the date of the request for treatment)

Covered health services must be provided: · When the Plan is in effect · Before the effective date of any of the individual termination conditions set forth in this SPD · Only when the person who receives services is enrolled and meets all eligibility requirements specified in the Plan Decisions about whether to cover new technologies, procedures, and treatments will be consistent with conclusions of prevailing medical research, based on well-conducted randomized trials or cohort studies accepted by the claims administrator

Eligible expenses

Eligible expenses are based on either of the following: · When covered health services are received from network providers, eligible expenses are the contracted fee(s) with those providers · When covered health services are received from out-of-network providers (emergency care or as preapproved by Aetna), the claim administrator calculates eligible expenses based on available data resources of competitive fees in that geographic area that are acceptable to the claim administrator These fees are referred to as reasonable and customary, or usual and customary, expenses Eligible expenses are determined solely in accordance with the claim administrator's reimbursement policy guidelines The reimbursement policy guidelines are developed, in the claim administrator's discretion, following evaluation and validation of provider billings in accordance with one or more of the following methodologies: · As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association · As reported by generally recognized professionals or publications · As used for Medicare · As determined by medical staff and outside medical consultants pursuant to other appropriate source or determination that the claims administrator accepts

Annual coinsurance maximum

After your coinsurance expenses reach a certain dollar amount, the Plan pays 100% of most remaining covered expenses for the rest of the calendar year See the "Your benefits and costs at a glance" chart on page 6 for amount

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The following expenses do not count toward your coinsurance maximum and are not payable by the Plan, even after meeting your annual coinsurance maximum: · Copays · Expenses not covered by the Plan or exceeding Plan limits · Expenses over the eligible expense · Expenses not considered a covered health service · Prescription drug copays or coinsurance

Walk-in clinics

You pay a $10 copay for services at an Aetna walk-in clinic Aetna walk-in clinics are network, freestanding health care facilities They are an alternative to a physician's office visit for treatment of unscheduled, nonemergency illnesses and injuries and the administration of certain immunizations They are not an alternative for emergency room services or the ongoing care provided by a physician Neither an emergency room, nor the outpatient department of a hospital, shall be considered a walk-in clinic

Using the Aetna Open Access and Aetna Select Networks

If you are enrolled in the Plan, you must follow specific procedures to be eligible for benefits You may directly access specialists and other health care professionals in the network Your network physician is the key to your benefits To identify providers who participate in the network, access the Provider Directory Service through Teamworks or at geoaccesscom/directoriesonline/wf If online access is not available, you may request a personalized directory by phone (See the "Contacts" section on page 1) Be aware that providers may discontinue their network association during the year It is your responsibility to ensure that the provider is still a network provider before you receive services

Urgent care

You pay a $40 copay per visit when you visit an Aenta urgent care facility There may be situations when an injury or illness is not life-threatening or likely to cause serious impairment but requires prompt medical attention If you require this type of nonemergency care and your network physician is not available, you may be able to access one of Aetna's urgent care facilities if there's one in your area Check with Aetna customer service to see if there is an urgent care facility in your area Non-urgent use of urgent care providers is not covered

In an emergency

For emergency room services (as long as you meet theAetna Emergency Care criteria), you pay a $100 copay, then the plan pays 100% of eligible covered expenses If you are admitted, you pay the hospital coinsurance of 10% (of eligible covered expenses) In a true medical emergency, there's no time to contact Aetna, so the process works a little differently You may go to any hospital for treatment Emergency services are always covered, 24 hours a day, 7 days a week, no matter where you are If you have been treated for an emergency, call your network physician (or have someone call for you) for further assistance and directions on follow-up care When possible, you should call within 48 hours (See the "Emergency care" section on page 17) Nonemergency use of the emergency room is not covered

Specialists

If you see a network specialist, no referral is necessary, and you will receive network benefits If you are referred to an out-of-network specialist, you must receive an authorized referral from Aetna before you receive services After receiving authorization, the first visit is covered at the network benefit level Before receiving additional services, you are again responsible for obtaining the necessary authorization from Aetna If you do not receive written authorization from Aetna, services will not be covered

OB/GYN providers

Women may visit a network obstetrician or gynecologist at any time for OB/GYN-related and maternity care issues only You may not use an OB/GYN for routine physicals or non-OB/GYN services

Emergency and urgent care

You will pay $100 copay (the copay will be waived if admitted) Nonemergency care in the ER is not covered You have coverage 24 hours a day, 7 days a week, anywhere inside or outside the Plan's service area, for: · An emergency medical condition · An urgent condition

Paying for in-network benefits

When you visit your network physician, present your identification card and pay $25 for the office visit

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Aetna EPO Plan

In case of a medical emergency When emergency care is necessary, please follow the guidelines below:

· Seek the nearest emergency room, or dial 911 or your local emergency response service for medical and ambulatory assistance If possible, call your provider provided a delay would not be detrimental to your health · After assessing and stabilizing your condition, the emergency room should contact your provider to obtain your medical history to assist the emergency provider in your treatment · If you are admitted to an inpatient facility, notify your provider as soon as reasonably possible · If you seek care in an emergency room for a nonemergency condition (one that does not meet the criteria above), the Plan will not cover the expenses you incur

Please contact your provider after receiving treatment of an urgent condition If you visit an urgent care provider for a non-urgent condition, the Plan will not cover your expenses If you or an enrolled dependent requires emergency care (usually because the person is a threat to his or her own life or to others): 1 Call Aetna Behavioral Health at 1-888-802-4271 if there is time -- it will do one of the following: ­ Refer you to a network facility or psychiatrist for an emergency evaluation ­ Instruct you to go to the nearest hospital

emergency room

2 For emergency inpatient admissions, the facility must call Aetna Behavioral Health within 48 hours, or as soon as reasonably possible, of the admission It is your responsibility to make sure the facility contacts Aetna so the admission can be reviewed to determine if it is medically necessary and eligible for plan benefits If Aetna is not notified of emergency inpatient admissions services, you may not receive benefits for those services You can also contact EAC for assistance with psychiatric emergencies For more information, see "Urgent care claim" in "Appendix A: Claims and appeals" in your Benefits Book You have coverage 24 hours a day, 7 days a week, anywhere inside or outside the Plan's service area, for: · An emergency medical condition · An urgent condition

Coverage for emergency medical conditions Covered expenses include charges made by a hospital or a physician for services provided in an emergency room to evaluate and treat an emergency medical condition The emergency care benefit covers:

· Use of emergency room facilities · Emergency room physicians' services · Hospital nursing staff services · Radiologists' and pathologists' services Please contact your provider after receiving treatment for an emergency medical condition With the exception of urgent care described below, if you visit a hospital emergency room for a nonemergency condition, the Plan will not cover your expenses No other plan benefits will pay for nonemergency care in the emergency room

In case of a medical emergency When emergency care is necessary, please follow the guidelines below:

· Seek the nearest emergency room, or dial 911 or your local emergency response service for medical and ambulatory assistance If possible, call your provider provided a delay would not be detrimental to your health · After assessing and stabilizing your condition, the emergency room should contact your provider to obtain your medical history to assist the emergency physician in your treatment · If you are admitted to an inpatient facility, notify your provider as soon as reasonably possible

Coverage for urgent conditions Covered expenses include charges made by a hospital or urgent care provider to evaluate and treat an urgent condition Your coverage includes:

· Use of emergency room facilities when network urgent care facilities are not in the service area and you cannot reasonably wait to visit your provider · Use of urgent care facilities · Physicians' services · Nursing staff services · Radiologists' and pathologists' services

Nonemergency care away from home

When you are traveling outside the Plan area, there may be situations that require prompt medical attention but are not considered emergencies If you have an urgent care situation, call your network physician or Aetna directly

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Health Information Line

Through Aetna's 24-Hour Health Information Line, a nurse is only a phone call away Twenty-four hours a day, 7 days a week, a specially trained team of registered nurses is on duty around the clock Your nurse will ask you a few questions about your symptoms and situation then direct you to the type of care that should make you more comfortable If you need urgent care, your nurse will direct you to the nearest qualified provider or facility and assist you with any necessary authorizations Call 1-800-556-1555 Simple voice prompts quickly guide you to the information you need

Allergy

You pay a $25 copay per visit for allergy injections

Ambulance

You pay 10% for eligible covered expenses · Ambulance service to the nearest hospital required for stabilization and initial medical treatment for an emergency situation · To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services or facilities to treat the member · Air or water ambulance to the nearest facility qualified to give the required treatment when ground ambulance transportation is not medically appropriate because of the distance involved, or because the member has an unstable condition requiring medical supervision and rapid transport · Ambulance transport from a skilled nursing facility or rehabilitation facility to another facility or hospital for tests or diagnosis when such tests or diagnostics cannot be rendered at the facility · From home to hospital or another facility for covered inpatient or outpatient treatment when other means of transportation would be considered unsafe due to your medical condition Transport is limited to 100 miles Not covered: · Ambulance services not listed above · Nonemergencies · Transportation services that are not medically necessary for basic or advanced life support · Transportation services that are mainly for your convenience Also refer to the "What is not covered" section on page 27

What the Plan covers

The Plan covers certain treatments for illness, injury, and pregnancy (See the "Covered health services" section on page 11 for more detail) Coverage is not necessarily limited to services and supplies described in this section, but do not assume that an unlisted service is covered If you have questions about coverage, call Aetna These services are subject to the limitations, exclusions, and procedures described in this SPD When more than one definition or provision applies to a service, the most restrictive applies and exclusions take precedence over general benefit descriptions The Plan only covers care provided by health care professionals or facilities licensed, certified, or otherwise qualified under state law to provide health care services and acting within the scope of their licensureship or certification

Acupuncture

You pay a $25 copay for each visit The Plan covers services of an in-network licensed or certified physician, chiropractor, or acupuncturist acting within the scope of that license or certification, limited to 26 visits per calendar year Coverage is provided for treatment of an illness or injury, to alleviate chronic pain, or for anesthesia in connection with a covered surgical procedure Covered health services included treatment of nausea as a result of the following: · Chemotherapy · Pregnancy · Postoperative procedures For more information on what is covered under the Aetna plan refer to Aetna's policies at aetnacom For exceptions, refer to the "What is not covered" section on page 27

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Bariatric services

See the "Morbid obesity" section on page 21

Chiropractic care

You pay a $25 copay for each visit The Plan provides benefits for spinal treatment when provided by a network provider in the provider's office Benefits include diagnosis and related services and are limited to 26 visits per calendar year Not covered: · Therapy, service, or supply, including but not limited to spinal manipulations by a chiropractor or other doctor, for the nontherapeutic treatment of

Aetna EPO Plan

a condition, such as treatment to maintain a level of functioning or prevent a medical problem from occurring or reoccurring · Spinal treatment, including chiropractic manipulative treatment to treat an illness, such as asthma or allergies Also refer to the "What is not covered" section on page 27

trauma to face and mouth only, not for cracked or broken teeth that result from biting or chewing · Treatment of cleft lip and palate for a dependent child under age 18 · Orthognathic surgery that meets the reconstructive surgery provisions on page 24 and the Aetna criteria · Dental x-rays, supplies, and appliances, and all associated expenses, including hospitalizations and anesthesia necessary to: ­ Prepare for transplant ­ Initiate immunosuppressives ­ Diagnose cancer ­ Directly treat current instance of cancer Not covered, regardless of whether treatment is medical or dental in nature: · Dental implants and all associated expenses · Dental braces or orthodontia services and all associated expenses · Oral appliances except as needed for medical conditions affecting temporomandibular joint dysfunction (TMJ) or if approved by Aetna due to accident or injury · Dental x-rays, supplies, and appliances and all associated expenses, including hospitalizations and anesthesia, except as noted above · Oral surgery, and all associated expenses, including hospitalizations and anesthesia, except as noted above · Preventive care, diagnosis, and treatment of or related to the teeth, jawbones, or gums, and all associated expenses, including hospitalizations and anesthesia, except as noted above · Treatment of congenitally missing, malpositioned, or supernumerary teeth, even if part of a congenital anomaly, and all associated expenses, including hospitalizations and anesthesia, except as noted above Also refer to the "What is not covered" section on page 27

Dental care

You pay 10% of eligible covered expenses The Plan covers certain medically necessary hospital services for dental care (See the "Covered health services" section on page 11) This is limited to charges incurred by a covered person who: · Is a child under age five · Is a child between the ages of five and 12 and where either of the following is true: ­ Care in dental offices has been attempted

unsuccessfully and usual methods of behavior

modification have not been successful

­ Extensive amounts of restorative care, exceeding four appointments, are required · Is severely disabled · Has any of the conditions listed below, requiring hospitalization or general anesthesia for dental care treatment: ­ Respiratory illnesses ­ Cardiac conditions ­ Bleeding disorders ­ Severe risk of compromised airway ­ Extensive procedures that prevent an oral surgeon from providing general anesthesia in the office setting, regardless of age ­ Psychological barriers to receiving dental care,

regardless of age

The above coverage is limited to facility and anesthesia charges Oral surgeon or dentist professional fees are not covered Covered services are determined based on established medical policies, which are subject to periodic review and modification by the medical directors The Plan also covers: · Treatment from a physician or dentist for an accidental injury to sound natural teeth completed in the calendar year of the accident or the next calendar year; coverage is for damage caused by external

Durable medical equipment, prosthetics, and supplies

Durable medical equipment and supplies You pay 10% of eligible covered expenses The Plan provides benefits for durable medical equipment and supplies that meet each of the following criteria:

· Ordered, prescribed, or provided by a physician for outpatient use for the patient's diagnosed condition

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· Used for medical purposes · Equipment, appliances, and devices cannot be consumable or disposable · Not of use to a person in the absence of a disease or disability · For orthotic appliances and devices, the items must be custom manufactured or custom fitted to the patient for diagnosed condition · Suitable for use in the home If more than one piece of durable medical equipment or prosthetic device can meet your functional needs, benefits are available only for the most cost-effective piece of equipment The Plan provides benefits for a single unit of durable medical equipment (for example, one insulin pump) Benefits are provided for the repair or replacement of a type of durable medical equipment once every three calendar years unless there is a change in the covered person's medical condition which requires repair or replacement sooner (eg, due to growth of a dependent child) Covered durable medical equipment includes but is not limited to: · Insulin pumps · Wheelchair · Standard hospital bed · Delivery pumps for tube feeding · Mechanical equipment necessary for the treatment of chronic or acute respiratory failure or conditions · Oxygen concentrator units and equipment rental to administer oxygen Covered supplies: · Surgical dressings, casts, splints, trusses, and crutches · Ostomy supplies · Noncorrective contact lens bandage Not covered: · Supplies, equipment, and similar incidental services and supplies for personal comfort, regardless of medical need, including but not limited to air conditioners; air purifiers, and filters; batteries and battery charges; dehumidifiers; home remodeling to accommodate a health need (such as ramps and swimming pools); and vehicle enhancements · Devices used specifically as safety items or to affect performance in sports-related activities · Prescribed or nonprescribed medical supplies and disposable supplies, including ace bandages, gauze, and dressings

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· Tubings, nasal cannulas, connectors, and masks are not covered except when used with durable medical equipment · Eyeglasses or contact lenses except for the patients with aphakia · Hearing aids (except for children up through age 18 as noted under the "Hearing aids" section on page 18) · Fitting charge for eyeglasses, with the exception for patient's with aphakia Also refer to the "What is not covered" section on page 27

Prosthetics You pay 10% of eligible covered expenses The Plan covers prosthetic devices that replace a limb or body part, including artificial limbs and artificial eyes It also covers breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998 If more than one prosthetic device can meet your functional needs, benefits are available only for the most cost-effective prosthetic device, as determined by Aetna

The prosthetic device must be ordered or provided by, or under the direction of a physician · External prosthetic appliances and devices You pay 10% of eligible covered expenses Any charges made or ordered by a physician for the initial purchase and fitting of external prosthetic appliances and devices available only by prescription and necessary for the alleviation or correction of injury, sickness, or congenital defect External prosthetic appliances and devices shall

include prostheses and prosthetic appliances

and devices

The following are specifically excluded external prosthetic appliances and devices: · External and internal power enhancements or power controls for prosthetic limbs and terminal devices · Myoelectric prostheses peripheral nerve stimulators Also refer to the "What is not covered" section on page 27 · Prostheses or prosthetic appliances and devices You pay 10% of eligible covered expenses Prostheses or prosthetic appliances and devices are defined as fabricated replacements for missing body parts Prostheses or prosthetic appliances and devices include, but are not limited to: ­ Basic limb prostheses ­ Terminal devices such as hands or hooks ­ Speech prostheses

Aetna EPO Plan

Also refer to the "What is not covered" section on page 27 Orthoses and orthotic devices You pay 10% of eligible covered expenses Orthoses and orthotic devices are defined as orthopedic appliances or apparatuses used to support, align, prevent, or correct deformities Coverage is provided for custom foot orthoses and other orthoses as follows: · Nonfoot orthoses Only the following nonfoot orthoses are covered: ­ Rigid and semirigid custom fabricated orthoses ­ Semirigid prefabricated and flexible orthoses ­ Rigid prefabricated orthoses, including preparation, fitting, and basic additions, such as bars and joints ­ Cranial banding and cranial orthoses · Custom foot orthoses Custom foot orthoses are only covered as follows: ­ For persons with impaired peripheral sensation

or altered peripheral circulation (eg, diabetic

neuropathy and peripheral vascular disease)

­ When the foot orthosis is an integral part of a leg brace and it is necessary for the proper functioning of the brace ­ When the foot orthosis is for use as a replacement or substitute for missing parts of the foot (eg, amputation) and is necessary for the alleviation or correction of injury, sickness, or congenital defect ­ For persons with neurologic or neuromuscular

conditions (eg, cerebral palsy, hemiplegia, spina

bifida) producing spasticity, malalignment, or

pathological positioning of the foot and there is

reasonable expectation of improvement

The following are specifically excluded orthoses and orthotic devices: · Prefabricated foot orthoses · Orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications, and transfers (except as needed for foot amputees) · Orthoses primarily used for cosmetic rather than functional reasons · Orthoses primarily for improved athletic performance or sports participation Also refer to the "What is not covered" section on page 27

Braces A brace is defined as an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body and that allows for motion of that part You pay 10% of eligible covered expenses The following braces are covered: · Braces that stabilize an injured body part, including adjustments to shoes to fit the brace (if applicable) · Braces to treat curvature of the spine The following braces are specifically excluded: Copes scoliosis braces Also refer to the "What is not covered" section on page 27 Splints A splint is defined as an appliance for preventing movement of a joint or for the fixation of displaced or movable parts You pay 10% of eligible covered expenses Also refer to the "What is not covered" section on page 27 Replacement of external prosthetic appliances and devices You pay 10% of eligible covered expenses Coverage for replacement of external prosthetic appliances and devices is limited to the following: · Replacement due to regular wear Replacement for damage due to abuse or misuse by the person will not be covered · Replacement due to anatomic change that has rendered the external prosthetic appliance or device ineffective Anatomic change includes significant weight gain or loss, atrophy, or growth

Emergency care

You pay a $100 copay (as long as you meet the Aetna criteria below), then the Plan pays 100% of eligible covered expenses (if admitted ER copay is waived, hospital 10% coinsurance will apply) The Plan covers emergency care services if, in the judgment of a reasonable person, immediate care and treatment is required, generally within 24 hours of onset, to avoid jeopardy to life or health as follows: · Placing your health in serious jeopardy · Serious impairment to bodily function · Serious dysfunction of a body part or organ · In the case of a pregnant woman, serious jeopardy to the health of the fetus

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Emergency room care provided for nonemergency purposes is not covered For exceptions, refer to the "What is not covered" section on page 27

· Services provided by a family member or a person living in your home · Services of a certified or licensed social worker · Transportation Also refer to the "What is not covered" section on page 27

Hearing aids

You pay 10% of eligible covered expenses Hearing aids are covered for dependents up through the calendar year in which the dependent child turns age 18 (limited to one every three calendar years) This would cover one hearing aid or one set, as needed Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear A hearing aid consists of a microphone, amplifier, and receiver Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a physician Benefits are provided for the hearing aid and for charges associated with fitting and testing

Extended skilled nursing care You pay 10% of eligible covered expenses Extended skilled nursing care is defined as the use of skilled nursing services delivered or supervised by a registered nurse (RN) or licensed practical nurse (LPN) to obtain the specified medical outcome and provide for the safety of the patient (Aetna refers to extended skilled nursing as private duty nursing) To be covered under the Plan:

· An attending physician must order extended skilled nursing care · Certification of the RN or LPN providing the care is required · The Plan, in its sole discretion, must determine that the extended skilled nursing care is medically necessary · The covered person and the provider must obtain prior authorization from the Plan (contact member services of the Plan to request prior authorization) Benefits are limited to 100 visits per calendar year combined with home health care Each 24-hour visit (or shifts of up to 24-hour visits) equal one visit and count towards the 100 combined visits Any visit that lasts less than 24 hours, regardless of the length of the visit, will count as one visit towards the 100 visit limitation (combined with home health care) Services provided under the following circumstances will be considered extended skilled nursing services: 1 Transition of the covered person from an inpatient setting to home 2 The covered person becomes acutely ill and the additional skilled nursing care will prevent a hospital admission 3 The covered person meets the clinical criteria for confinement in a skilled nursing facility, but a skilled nursing facility bed is not available In this situation, additional skilled nursing may be provided until a skilled nursing facility bed becomes available 4 The covered person is on a ventilator or is dependent on continuous positive airway pressure due to respiratory insufficiency at home

Home health care

You pay 10% of eligible covered expenses The Plan covers 100 visits per calendar year combined with extended skilled nursing One visit equals up to four hours of care service The Plan covers some home health care as an alternative to hospitalization All services under this benefit must be authorized by your network physician to be eligible for network coverage Covered home health care includes services that are ordered by a physician and provided by or supervised by a registered nurse in your home Benefits are available only when the home health agency services are provided on a part-time, intermittent schedule and when skilled home health care is required Skilled home health care is skilled nursing, teaching, and rehabilitation services provided by licensed technical or professional medical personnel to obtain a medical outcome and provide for the patient's safety Not covered: · Custodial care, maintenance, or home health care delivered for the purpose of assisting with activities of daily living, including but not limited to dressing, feeding, bathing, or transferring from a bed to a chair Custodial or maintenance care includes but is not limited to help in getting in and out of bed, walking, bathing, dressing, eating, and taking medication, as well as ostomy care, hygiene or incontinence care, and checking of routine vital signs This type of care is primarily required to meet the patient's personal needs or maintain a level of function, as opposed to improving that function to allow for a more independent existence The care does not require continued administration by trained medical personnel to be delivered safely and effectively

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Aetna EPO Plan

Not covered: · Nursing care that does not require the education, training, and technical skills of an RN or LPN · Nursing care provided for skilled observation · Nursing care provided while the covered person is an inpatient in a hospital or health care facility · Nursing care to administer routine maintenance medications or oral medications, except where law requires an RN or LPN to administer medicines · Custodial care for daily life activities such as but not limited to: ­ Transportation ­ Meal preparation ­ Vital sign charting ­ Companionship activities ­ Bathing ­ Feeding ­ Personal grooming ­ Dressing ­ Toileting ­ Getting in or out of bed or a chair · Services that can be safely and effectively performed by a nonmedical person or self-administered without the direct supervision of a licensed nurse The unavailability of a person to provide an unskilled service does not allow for coverage for a nurse to provide unskilled services

Hospital inpatient services

You pay 10% of eligible covered expenses (inpatient care or other care rendered in a hospital setting) Hospital costs including: · Semiprivate room and board · Intensive care and cardiac care · Miscellaneous medically appropriate hospital services and supplies, including operating room, except as noted below · X-ray and lab services, drugs, and anesthetics, and their administration · Physician and surgeon services received during the inpatient hospital stay · Assistant surgeon services ­ Covered expenses for assistant surgeon services are between 12% and 16% of the amount of covered expenses for the surgeon's charge for the surgery An assistant surgeon must be a physician · Administration of blood and blood products, including charges for self-donated blood Not covered: · Admission for diagnostic tests that can be performed on an outpatient basis · Comfort or convenience items, such as television, telephone, beauty or barber service, or guest service · Late charges for less than a full day of hospital confinement, if for patient convenience · Private duty nursing in a hospital (see the "Extended skilled nursing care" section on page 18 for more information) · Surgery that is intended to allow you to see better without glasses or other vision correction, including radial keratotomy, laser, and other refractive eye surgery Also refer to the "What is not covered" section on page 27

Hospice care

You pay 10% of eligible covered expenses Hospice care is recommended by a physician, coordinates home and inpatient care for individuals with a terminal illness (prognosis of 12 months or less), and must be provided by a licensed agency The Plan includes coverage for: · Inpatient care · Physician services · Palliative care · Respite care · In-home health care services, including nursing care, use of medical equipment, wheelchair and bed rental, and home health aide care · Physical and chemical therapies · Bereavement counseling for covered family members if provided as part of the hospice care program For exceptions, refer to the "What is not covered" section on page 27

Aetna EPO Plan

Infertility and fertility treatment

You pay a $25 copay for eligible covered services performed in a physician's office For services performed in a hospital or outpatient facility, you pay 10% of eligible covered expenses Infertility treatment is limited to a lifetime maximum benefit of $10,000, for diagnosis and treatment for correction of underlying conditions and artificial insemination

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Eligible covered expenses, even though not incurred for treatment of an illness or injury, will include expenses incurred by an eligible covered female for infertility if all of the following tests are met: · A condition that is a demonstrated cause of infertility which has been recognized by a gynecologist, or a network infertility specialist, and your physician who diagnosed you as infertile, and it has been documented in your medical records · The procedures are done while not confined in a hospital or any other facility as an inpatient · Your FSH levels are less than 19 miU on day three of the menstrual cycle · A successful pregnancy cannot be attained through less costly treatment for which coverage is available under this SPD · If you meet the eligibility requirements above, the following comprehensive infertility services expenses are payable when provided by a network infertility specialist upon preauthorization by Aetna, subject to all the exclusions and limitations of this SPD · Intrauterine insemination is subject to the maximum benefit of $10,000 per lifetime (where lifetime is defined to include services received, provided, or administered by Aetna or any affiliated company of Aetna)

· Injectable infertility medications, including but not limited to menotropins, hCG, GnRH agonists, and IVIG · Any services or supplies provided without preauthorization from Aetna's infertility case management unit · Infertility services that are not reasonably likely to result in success · Intrauterine insemination services if you are not infertile · Services and supplies furnished by an out-of network provider · Any ART procedure or services related to such procedures, including but not limited to in vitro fertilization ("IVF"), gamete intra-fallopian transfer ("GIFT"), zygote intra-fallopian transfer ("ZIFT"), and intra-cytoplasmic sperm injection ("ICSI") · Any charges associated with care required to obtain ART services (eg, office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for any ART procedures · Surrogate parenting · Fees or direct payments for sperm or ovum donations · Monthly fees for maintenance or storage of sperm, ovum, or frozen embryo · Prescription drugs associated with infertility or fertility treatment Also refer to the "What is not covered" section on page 27

Exclusions and limitations Unless otherwise specified above, the following charges will not be payable as covered expenses under this SPD:

· Infertility services for couples in which one of the partners has had a previous sterilization procedure, with or without surgical reversal · Reversal of sterilization surgery · Infertility services for females with FSH levels 19 or greater mIU/ml on day three of the menstrual cycle · The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers (or surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational carrier · Charges associated with cryopreservation or storage of cryopreserved eggs and embryos (eg, office, hospital, ultrasounds, laboratory tests, etc) · Home ovulation prediction kits · Drugs related to the treatment of noncovered benefit

Maternity care

You pay a $25 copay for the first visit to confirm pregnancy All subsequent prenatal and postnatal visits, as part of the global obstetrics (OB) package, are subject to 10% (coinsurance) of eligible covered expenses For prenatal and postnatal visits outside of the global OB package, you pay a $25 copay For delivery (hospital inpatient and physician charges), you pay 10% of eligible covered expenses The global OB package includes all maternity-related medical services for prenatal care, postnatal care, delivery, and any related complications In order for the Plan to cover charges for your newborn child, you must add the child to your coverage through Wells Fargo within 60 days of the birth See "Chapter 1: An introduction to your benefits" in your Benefits Book for information about adding new dependents

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Aetna EPO Plan

If the child is added to Wells Fargo medical benefits as described above, the Plan will pay benefits for an inpatient stay, as measured from the time of delivery: · 48 hours for the mother and newborn child following a normal delivery · 96 hours for the mother and newborn child following a cesarean section delivery Your provider does not need authorization from the Plan to prescribe a hospital stay of this length However, additional days beyond 48 or 96 hours require authorization If the mother agrees, the attending provider may discharge the mother or the newborn child earlier than these minimum stays In-home midwives, birthing centers, and fetal monitors (including intrauterine devices) are covered with Aetna approval Services need to be at an Aetna participating provider Refer to the "Preventive care services" section on page 22 for information on newborn coverage For exceptions, refer to the "What is not covered" section on page 27

Nutritional formulas

You pay 10% of eligible covered expenses The Plan covers nutritional formulas ordered by your network physician and is limited to medically necessary formulas for malabsorption when used as the treatment of an inborn metabolic disorder such as phenylketonuria (PKU) Not covered: · Enteral feedings and other nutritional and electrolyte supplements, including infant formula, donor breast milk, nutritional supplements, and dietary supplements (except when used as the definitive treatment of an inborn metabolic disorder, such as PKU) · Diets for weight control or treatment of obesity (including liquid diets or food) · Food, food substitutes, or food supplements of any kind (diabetic, low fat, cholesterol, infant formula, etc) · Over-the-counter oral vitamins and oral minerals · Megavitamin and nutrition-based therapy · Nutritional counseling for either individuals or groups except as noted below, including weight loss programs, health clubs, and spa programs Also refer to the "What is not covered" section on page 27

Morbid obesity

For individuals with a body mass index of 35 or greater, coverage may be available for gastric bypass or lap-band surgery if specific criteria are met Call Aetna to begin the evaluation process You pay 10% of eligible covered expenses for bariatric services All bariatric services must be received at an Aetna designated Institutes of Quality facility to be covered Any services received outside of a designated Institutes of Quality facility are not covered and no benefits will be paid A designated Institutes of Quality provider or facility may or may not be located within your geographic area Depending on the location of this designated facility, you may be eligible for reimbursement of a portion of transportation and lodging Not covered: · All other weight loss-related services, supplies, or treatments · Surgery to remove excess skin after successful weight loss, regardless of need · Repeat weight loss surgery, which is a second or subsequent procedure performed, regardless of type of weight loss surgery performed and regardless of coverage at the time of the previous procedure Also refer to the "What is not covered" section on page 27

Nutritionists

You pay 10% of eligible covered expenses The Plan will pay for nutritional counseling provided in a network physician's office by an appropriately licensed nutritionist, dietician, or health care professional when education is required for a disease in which patient self-management is an important component of treatment, and there exists a knowledge deficit regarding the disease that requires the intervention of a trained health professional Some examples of such medical conditions include: · Coronary artery disease · Congestive heart failure · Severe obstructive airway disease · Gout (a form of arthritis) · Renal failure · Phenylketonuria (a genetic disorder diagnosed at infancy) · Hyperlipidemia (excess of fatty substances in the blood)

Aetna EPO Plan

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Not covered: · Nutritional counseling for either individuals or groups, in connection with weight loss programs, health clubs, and spa programs For exceptions, refer to the "What is not covered" section on page 27

· Lab and x-ray · Mammography testing For exceptions, refer to the "What is not covered" section on page 27

Physician services

You pay a $25 copay if performed as part of a physician office visit and billed by a physician You pay 10% of eligible covered expenses for outpatient and inpatient services (this may include lab and x-ray services) If you are enrolled in the Plan, your network physician will provide you with services or refer you to a specialist if necessary Physician services include: · Allergy testing, serum, and injections · Inpatient hospital or facility visits · Office visits for illness · Outpatient hospital or facility visits · Preventive care · E-visits Covered expenses include charges made by your primary doctor for a routine, nonemergency, medical consultation You must make your e-visit through an Aetna-authorized internet service vendor You may have to register with that internet service vendor · Surgery · Treatment of eye disease Not covered: · Charges for a physician who does not perform a service, but is on call · Routine physical examinations not required for health reasons, including but not limited to employment, insurance, government license, court-ordered, forensic, or custodial evaluations Also refer to the "What is not covered" section on page 27

Outpatient surgery You pay 10% of eligible covered expenses The Plan covers services received on an outpatient basis at a hospital or alternate facility including:

· Scheduled surgery, anesthesia, and related services When more than one surgical procedure is performed, surgical procedures are reimbursed as follows: ­ Primary procedure -- allow 100% of the

eligible expense

­ Secondary procedure -- allow 50% of the

eligible expense

­ Tertiary and additional procedures -- allow 25%

of the eligible expense

Covered expenses for assistant surgeon services are between 12% and 16% of the amount of covered expenses for the surgeon's charge for the surgery An assistant surgeon must be a physician

Physician A licensed member of a medical profession who:

· Has an MD or DO degree · Is properly licensed or certified to provide medical care under the laws of the jurisdiction where the individual practices · Provides medical services that are within the scope of his or her license or certificate This also includes a health professional who: · Is properly licensed or certified to provide medical care under the laws of the jurisdiction where he or she practices · Provides medical services that are within the scope of his or her license or certificate · Under applicable insurance law is considered a "physician" for purposes of this coverage · Has the medical training and clinical expertise suitable to treat your condition

Diagnostic and therapeutic services You pay a $25 copay if performed as part of a physician office visit and billed by a physician You pay 10% of eligible covered expenses if performed as part of a physician office visit and the physician sends it out to an independent lab You pay 10% of eligible covered expenses if performed in an outpatient hospital or freestanding facility setting including independent lab

· Radiation and chemotherapy · Kidney dialysis

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Preventive care services

The Plan covers in-network, eligible preventive care services at 100% In order for a service to be considered an eligible preventive care service, it must be a preventive care service recommended by one of several federal government or independent agencies responsible for the development and monitoring of

Aetna EPO Plan

various US preventive care guidelines Many of the guidelines take into account gender, age, and you or your family's medical history

Services not considered preventive care services: · Services that are not recommended by one of several federal government or independent agencies responsible for the development and monitoring of various US preventive care guidelines · Although recommended by one of several government or independent agencies responsible for the development and monitoring of US preventive care guidelines, services that do not follow the government or independent agency's age, gender, or family history recommended guidelines · Services the provider submits to the Plan coded as nonroutine, which may include: ­ Office visits, screenings, lab work, tests, or procedures to diagnose a condition, treat a specific illness, or monitor an existing condition ­ Additional office visits, lab works, tests, or procedures recommended or required as a result of a preventive care visit, lab work, test, or procedure ­ Office visits, screenings, lab work, tests, or procedures if a condition or diagnosis is detected ­ Part of the services received that the provider submits to the Plan coded as nonroutine (ie, office visit, lab work, tests, or procedures) You may be required to pay $25 copay or 10% coinsurance if you receive eligible preventive care services at the same time you receive certain services that are not considered eligible preventive care services For example, if you see your provider for a recurring medical problem, but also receive an eligible preventive care service, the provider may submit the claim as a nonpreventive care office visit You would then be responsible for the nonpreventive care office visit copay or coinsurance amount However, the provider may submit separate claims for the preventive and nonpreventive services or treatments If the primary purpose of your visit is for preventive care services (eg, an annual physical exam), but you also discuss other health problems during the visit (eg, a recurring medical problem), your provider may submit the claim as an eligible preventive care service or the provider may submit separate claims for the preventive and nonpreventive services or treatments If you have questions about how claims for your office visit, screenings, lab work, tests, or procedures will be submitted to the Plan, talk to your provider about the type of care you receive or are recommended to receive before the claim is submitted to the Plan Once the claim is submitted to the Plan, the claim will be processed based on how your provider coded the claim

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Preventive care services for children As recommended under the Bright Futures guidelines, developed by the Health Resources and Services Administration with the American Academy of Pediatrics, the types of services for children covered as preventive care services include but are not limited to:

· Well-baby care physical exams · Well-child care physical exams · Vision and hearing screenings · Developmental assessments · Screening for depression and obesity

Routine vaccines As recommended by the Center for Disease Control's Advisory Committee on Immunization Practices, the types of routine vaccines covered as preventive care services include but are not limited to:

· Routine childhood immunizations such as diphtheria, tetanus, pertussis, polio, chicken pox, measles, mumps, rubella, hepatitis A and B, pneumococcal, meningococcal, rotavirus, human papillomavirus, flu · Routine vaccinations for adults such as flu, pneumococcal, tetanus, diphtheria, Zoster

Preventive care services for adults As recommended by the US Preventive Services Task Force, the types of services covered as preventive care services for adults include but are not limited to the following services that have a current rating of A or B:

· Adult routine physical exams · Routine screenings such as blood pressure, cholesterol, diabetes · Routine screenings such as mammography, colonoscopy, pap smear, PSA test · Routine gynecological exams · Bone density tests · Routine prenatal and postnatal care and exams · Screening for depression and obesity Your provider will inform the Plan what services you received when the provider submits the claim to the Plan for processing If the claim is coded as an eligible preventive care service with a routine diagnosis code, the claim will be paid as a preventive care service

Aetna EPO Plan

(ie, services coded by your provider as routine services will be processed as routine services) For additional information on preventive care coverage under the Plan, visit the Plan's website or call Aetna's Member Services department

Skilled nursing facility

You pay 10% of eligible covered expenses The Plan covers services for an inpatient stay in a skilled nursing facility or inpatient rehabilitation facility Benefits are limited to 100 days per calendar year Benefits are available for: · Services and supplies received during the inpatient stay · Room and board in a semiprivate room (a room with two or more beds) Skilled nursing provides benefits if you are convalescing from an injury or illness that requires an intensity of care or a combination of skilled nursing, rehabilitation, and facility services that are less than those of a general acute hospital but greater than those available in the home setting You are expected to improve to a predictable level of recovery Benefits are available only when skilled nursing, rehabilitation services, or both are needed on a daily basis Benefits are not available when these services are required intermittently (such as physical therapy three times a week) Not covered: · Custodial, domiciliary, or maintenance care (including administration of enteral feeds), even when ordered by a physician Custodial, domiciliary, or maintenance care includes, but is not limited to help in getting in and out of bed, walking, bathing, dressing, eating, and taking medication, as well as ostomy care, hygiene or incontinence care, and checking of routine vital signs It is primarily required to meet the patient's personal needs or maintain a level of function, as opposed to improving that function to allow for a more independent existence · Treatment for drug addiction, alcoholism, senility, mental retardation, or any other mental illness Also refer to the "What is not covered" section on page 27

Reconstructive surgery

You pay 10% of eligible covered expenses The Plan covers certain reconstructive procedures Services are considered reconstructive procedures when a physical impairment exists and the primary purpose of the procedure is to improve or restore physiologic function for an organ or body part to address any of the following: · For prompt repair of accidental injury that occurs while covered under the Plan · To improve function of a malformed body part · To correct a defect caused by infection or disease The Plan also covers the cost of postmastectomy reconstructive surgery performed on you or your eligible covered dependents in a manner determined in consultation with the attending physician and patient for: · Reconstruction of the breast on which the mastectomy was performed · Surgery and reconstruction of the other breast to produce a symmetrical appearance · Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas All of the Plan provisions continue to apply The same coinsurance that applies to the mastectomy surgery applies to postmastectomy reconstructive surgery If you have any questions regarding postmastectomy reconstructive surgery coverage, contact Aetna customer service Not covered: · Cosmetic procedures, including but not limited to pharmacological regimens, nutritional procedures or treatments, scar or tattoo removal or revision procedures, or skin abrasion · Liposuction · Removal of excess skin due to weight loss, regardless of the need · Replacement of an existing breast implant if the earlier breast implant was performed as a cosmetic procedure · Scar revision · Services related to teeth, the root structure of teeth or supporting bone and tissue; see the "Dental care" section on page 15

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Temporomandibular joint dysfunction (TMJ)

You pay $25 copay if performed in an office visit or 10% coinsurance of eligible covered expenses for outpatient and inpatient services With preauthorization, the Plan covers diagnosis and treatment of medical conditions affecting the temporomandibular joint when provided by or under the direction of a physician Coverage includes necessary treatment required as a result of accident, trauma, a congenital anomaly, developmental defect, or pathology

Aetna EPO Plan

Not covered: · Charges for services that are dental in nature · Charges for appliance therapy and tooth reconstruction, unless needed as the result of an accident

Not covered: · Speech therapy for voice modulation, articulation, or similar training (including to teach people to speak another language) · Speech therapy to treat stuttering, stammering, or the elimination of a lisp · Therapy to improve general physical condition · Cardiac and pulmonary rehabilitation, unless determined to be medically necessary by Aetna · Speech therapy except noted as above · Any type of therapy, service, or supply for the treatment of a condition when the therapy, service, or supply ceases to be therapeutic treatment; therapy is excluded if it is administered to maintain a level of functioning or to prevent a medical problem from occurring or reoccurring or if objective measurable progress is not being documented · Eye exercise or vision therapy · Hippotherapy · Prolotherapy · Therapy that has not been approved by Aetna or that does not meet Aetna criteria guidelines · Habilatative therapy beyond the age limit of the year in which the dependent child turns age 18 Also refer to the "What is not covered" section on page 27

Therapy or short-term rehabilitation

You pay a $25 copay per visit The Plan provides benefits for the following types of outpatient services: · Physical therapy · Occupational therapy · Speech therapy · Cardiac rehabilitation · Pulmonary rehabilitation Benefits are limited to 90 visits per calendar year for physical therapy, occupational therapy, and speech therapy combined Rehabilitation services are only covered to restore previously attained function lost due to injury or illness Benefits are available only for rehabilitation services that are expected to result in significant physical improvement in your condition within two months of the start of treatment Initial evaluation visit chart notes and an updated treatment plan, including a progress report with measurable objectives and how those objectives have been or will be met, are necessary to validate progress and the need for future visits whether the provider is in or out of network Habilitative services are only covered for children up through the calendar year in which they turn age 18 who have failed to acquire the speech or motor skills expected of a person of their particular age, as determined by the claims administrator, due to one of the following: · Developmental delay or developmental apraxia or dyspraxia · Hearing impairment · Major congenital anomalies for which corrective surgery has been performed (such as cleft lip and cleft palate) The habilitative services criteria above includes speech therapy, physical therapy, and occupational therapy An initial evaluation visit, chart notes, and an updated treatment plan including a progress report with measurable objectives and how those objectives have been or will be met, are necessary to validate progress and the need for future visits, whether the provider is in or out of network

Transgender services

You pay 10% of eligible covered expenses The Plan covers many of the charges incurred for transgender surgery (also known as gender reassignment surgery) for covered persons who meet all of the conditions for coverage Contact Aetna for information about conditions for coverage Transgender surgery benefits are limited to one surgery per covered person per lifetime For transgender surgery benefits, the criteria for diagnosis and treatment are based on the guidelines set forth by the World Professional Association for Transgender Health (WPATH), formerly known as the Harry Benjamin International Gender Dysphoria Association, Inc (HBIGDA)

Voluntary transplant program

Organ or tissue transplants You pay 10% of eligible covered expenses Services and supplies for medically necessary (see the "Covered health services" section on page 11) organ or tissue transplants through the Institutes of Quality are

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Aetna EPO Plan

payable under this Plan when they are coordinated with your network physician and Aetna Covered expenses include charges incurred during a transplant occurrence The following will be considered to be one transplant occurrence, once it has been determined that you or one of your dependents may require an organ transplant (Organ means solid organ, stem cell, bone marrow, and tissue) · Heart · Lung · Heart and lung · Simultaneous pancreas kidney (SPK) · Pancreas · Kidney · Liver · Intestine · Bone marrow or stem cell · Multiple organs replaced during one transplant surgery · Tandem transplants (stem cell) · Sequential transplants · Retransplant of same organ type within 180 days of the first transplant · Any other single organ transplant, unless otherwise excluded under the Plan The following will be considered to be more than one transplant occurrence: · Autologous blood or bone marrow transplant followed by allogenic blood or bone marrow transplant (when not part of a tandem transplant) · Allogenic blood or bone marrow transplant followed by an autologous blood or bone marrow transplant (when not part of a tandem transplant) · Retransplant after 180 days of the first transplant · Pancreas transplant following a kidney transplant · A transplant necessitated by an additional organ failure during the original transplant surgery or process · More than one transplant when not performed as part of a planned tandem or sequential transplant (eg, a liver transplant with subsequent heart transplant) The network level of benefits is paid only for a treatment received at a facility designated by the Plan as an Institutes of Quality for the type of transplant being performed Each Institutes of Quality facility has been selected to perform only certain types of transplants

26

The Plan covers eligible expenses for covered health services associated with: · Charges made by a physician or transplant team · Charges made by a hospital, outpatient facility, or physician for the medical and surgical expenses of a live donor, but only to the extent not covered by another plan or program · Related supplies and services provided by the facility during the transplant process These services and supplies may include physical, speech, and occupational therapy; biomedicals and immunosuppressants; home health care expenses; and home infusion services, subject to all other Plan terms · Charges for activating the donor search process with national registries · Compatibility testing of prospective organ donors who are immediate family members For the purpose of this coverage, an "immediate" family member is defined as a first-degree biological relative These are your biological parents, siblings, or children · Inpatient and outpatient expenses directly related to a transplant Covered transplant expenses are typically incurred during the four phases of transplant care described below Expenses incurred for one transplant during these four phases of care will be considered one transplant occurrence A transplant occurrence is considered to begin at the point of evaluation for a transplant and end either 180 days from the date of the transplant or upon the date you are discharged from the hospital or outpatient facility for the admission or visit(s) related to the transplant, whichever is later The four phases of one transplant occurrence and a summary of covered transplant expenses during each phase are: 1 Pretransplant evaluation and screening: Includes all transplant-related professional and technical components required for assessment and evaluation and acceptance into a transplant facility's transplant program 2 Pretransplant and candidacy screening: Includes HLA typing and compatibility testing of prospective organ donors who are immediate family members 3 Transplant event: Includes: ­ Inpatient and outpatient services for all covered transplant-related health services and supplies provided to you and a donor during the one or more surgical procedures or medical therapies for a transplant

Aetna EPO Plan

­ Prescription drugs provided during your inpatient stay or outpatient visit(s), including biomedical and immunosuppressant drugs ­ Physical, speech, or occupational therapy provided during your inpatient stay or outpatient visit(s) ­ Cadaveric and live donor organ procurement 4 Follow-up care: Includes all covered transplant expenses, home health care services, home infusion services, and transplant-related outpatient services rendered within 180 days from the date of the transplant event If you are a participant in the Institutes of Quality program, the program will coordinate all solid organ and bone marrow transplants and other specialized care you need Any covered expenses you incur from an Institutes of Quality facility will be considered network care expenses When significant travel is required to use an Institutes of Quality facility, the member may be eligible for travel and lodging allowances according to Aetna's standard internal policies and procedures The lifetime maximum benefit is $10,000 per covered person Please contact Aetna for more details Not covered: · Outpatient drugs including biomedicals and immunosuppressants not expressly related to an outpatient transplant occurrence · Services that are covered under any other part of this Plan · Services and supplies furnished to a donor when the recipient is not covered under this Plan · Home infusion therapy after the transplant occurrence · Harvesting or storage of organs, without the expectation of immediate transplantation for an existing illness · Harvesting or storage of bone marrow, tissue, or stem cells, without the expectation of transplantation within 12 months for an existing illness · Cornea (Corneal Graft with Amniotic Membrane) or Cartilage (autologous chondrocyte or autologous osteochondral mosaicplasty) transplants, unless otherwise authorized by Aetna

What is not covered

In addition to any other exclusions or limitations specified in Chapter 2 of this SPD, the Plan does not cover the following:

Alternative treatment

Includes acupressure, aromatherapy, hypnotism, massage therapy, naturopaths, rolfing, or other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health

Experimental, investigational, or unproven services

The fact that an experimental or investigational service or an unproven service, treatment, device, or pharmacological regimen is the only available treatment for a particular condition will not result in benefits if the procedure is considered to be experimental, investigational, or unproven in the treatment of that particular condition This includes experimental procedures or treatment methods not approved by the American Medical Association or the appropriate medical specialty society

Experimental or investigational procedure Medical, surgical, diagnostic, mental health, substance abuse, or other health care services, technologies, supplies, treatments, procedures, drug therapies, or devices that, at the time the utilization review organization or the claims administrator makes a determination regarding coverage in a particular case, are determined to be:

· Not approved by the US Food and Drug Administration (FDA) to be lawfully marketed for the proposed use, or not identified in the American Hospital Formulary Service or the United States Pharmacopeia Dispensing Information as appropriate for the proposed use · Subject to review and approval by any institutional review board for the proposed use · The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2, or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight If you have a life-threatening sickness or condition (one which is likely to cause death within one year of the request for treatment), Aetna may, in its discretion, determine that an experimental or investigational service meets the definition of a covered health service for that sickness or condition For this to take place, Aetna must determine that the procedure or treatment

27

Aetna EPO Plan

is promising, but unproven, and that the service uses a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health

· Weight loss programs, services, supplies, or treatment, whether or not they are under medical supervision or for medical reasons (except as noted in the "Morbid obesity" section on page 21) · Treatment, services, or supplies for unwanted hair growth · Wigs, regardless of the reason for the hair loss

Unproven services Services provided:

· Where reliable, authoritative evidence (as determined by Aetna) does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes as compared with the standard means of treatment or diagnosis · Where the conclusions determine that the treatment, service, or supply is not effective · Where conclusions are not based on trials that meet either of the following designs: ­ Well-conducted randomized controlled trials Two or more treatments are compared to each other, and the patient is not allowed to choose which treatment is received ­ Well-conducted cohort studies Patients who receive study treatment are compared to a group of patients who received standard therapy The comparison group must be nearly identical to the study treatment group Decisions about whether to cover new technologies, procedures, and treatments will be consistent with conclusions of prevailing medical research based on well-conducted randomized trials or cohort studies as determined by Aetna If you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), Aetna may, in its discretion, determine that an experimental or investigational service meets the definition of a covered health service for that sickness or condition For this to take place, Aetna must determine that the procedure or treatment is promising, but unproven, and that the service uses a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health

Providers

· Services performed by a provider who is a family member by birth or marriage, including spouse, brother, sister, parent, or child, including any service the provider may perform on himself or herself · Services performed by a provider with your same legal residence · Charges made by a physician for, or in connection with, surgery that exceed the following maximum when two or more surgical procedures are performed at one time Multiple surgical procedures are reimbursed as follows: ­ Primary procedure: allow 100% of the

eligible expense

­ Secondary procedure: allow 50% of the

eligible expense

­ Tertiary and additional procedures: allow 25% of the eligible expense · Unless under the direction of a physician, services performed by a provider with the following designations: CFA, CNM, CORT, CSA, CST, LCSA, LCST, LPN, LSA, LVN, OPA, RN, or SFA

Services provided under another plan

· Health services for which other coverage is required by federal, state, or local law to be purchased or provided through other arrangements, including but not limited to coverage required by Workers' Compensation, no-fault auto insurance, or similar legislation · If coverage under Workers' Compensation or similar legislation is optional for you because you could elect it, or could have it elected for you, benefits will not be paid for any injury, sickness, or mental illness that would have been covered under Workers' Compensation or similar legislation had that coverage been elected · Health services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you · Health services while on active military duty

Physical appearance

· Cosmetic procedures, which are procedures that change or improve appearance without significantly improving the primary physiological function of the body part on which the procedure was performed, as determined by Aetna · Physical conditioning programs, such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion or general motivation

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Aetna EPO Plan

· Charges payable under Medicare · Charges that the participant is entitled to payment by a public program other than Medicaid

· Claims filed more than 12 months after the date of treatment or services · Comfort or convenience items · Educational services (except for nutritional counseling as noted in the "Nutritionists" section on page 21 and the "Nutritional formulas" section on page 21) · Foot care except when needed for severe systemic disease This includes: ­ Hygienic and preventive maintenance foot care ­ Treatment of flat feet ­ Treatment of subluxation of the foot ­ Shoe orthotics (except as covered under custom

foot orthoses)

· Growth hormone therapy · Health services and supplies that do not meet the definition of a covered health service (see the "Covered health services" section on page 11) · Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Plan · Health services received after the date your coverage under the Plan ends, including health services for medical conditions arising before the date your coverage under the Plan ends · Hippotherapy · Interest or late fee charges due to untimely payment for services · Medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea · Medical and surgical treatment of excessive sweating (hyperhidrosis) · Pastoral counselors · Physical, psychiatric, or psychological exams, testing, vaccinations, immunizations, or treatments that are otherwise covered under the Plan when either: ­ Conducted for purposes of medical research ­ Related to judicial or administrative proceedings or orders ­ Required solely for purposes of career, education, sports or camp, employment, insurance, marriage, or adoption ­ Required to obtain or maintain a license of any type

Travel

· Health services provided in a foreign country, unless required as emergency health services See the "Emergency care" section on page 17 · Travel, transportation, or living expenses, whether or not services are prescribed by a physician Some travel expenses related to covered transplantation services may be reimbursed at the claims administrator's discretion

All other exclusions

· Accidents or injuries incurred while self-employed or employed by someone else for wages or profit, including farming · Any charge for services, supplies, or equipment advertised by the provider as free · Any charges by a provider sanctioned under a federal program for reason of fraud, abuse, or medical competency · Any charges for a resident in a teaching hospital where a faculty physician did not supervise services · Any charges for missed appointments, room or facility reservations, completion of claim forms, or record processing · Any charges for stand-by provider or facility when no actual services have been performed · Charges a network provider is required to write off · Charges for or associated with patient advocacy · Charges for services needed because the patient was engaged in an illegal activity when the injury occurred · Charges for the purchase or replacement of contact lenses, except the purchase of the first pair of contact lenses for patients with aphakia · Charges in excess of eligible expenses or in excess of any specified limitation · Charges made for routine refractions, eye exercises, and surgical treatment for correction of a refractive error, including radial keratotomy, when eyeglasses or contact lenses may be worn · Charges the provider is required to write off under another plan, when the other plan is primary payer over the Wells Fargo plan · Child care costs, including day care centers and individual child care

Aetna EPO Plan

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· Private duty nursing (see the "Extended skilled nursing care" section on page 18 for more information) · Private room charges · Prolotherapy · Psychosurgery · Rest cures · Routine vision and hearing screening · Surgical treatment of obesity, except as previously noted under the "Morbid obesity" section on page 21 · Treatment of benign gynecomastia (abnormal breast enlargement in males) · Treatment provided in connection with smoking cessation program (except as otherwise required under applicable federal law) · VNS therapy

Post-service claims

For services already received, a post-service claim must be filed with Aetna within 12 months from the date of service, whether you or the provider files the claim If you receive services from an out-of-network provider, you are responsible for ensuring the claim is filed correctly and on time even if the out-of-network provider offers to file the claim on your behalf You must complete the appropriate claim form and provide an itemized original bill* from your provider that includes the following: · Patient name, date of birth, and patient diagnosis · Date(s) of service · Procedure code(s) and descriptions of service(s) rendered · Charge for each service rendered · Service provider's name, address, and tax identification number

* Monthly statements or balance due bills are not acceptable Photocopies are only acceptable if you're covered by two plans and sent your primary payer the original bill

Claims and appeals

Generally, if you use a network provider, the provider will obtain necessary pre-service authorizations for services to be received from a network provider or facility Network providers will also file post-service claims for service they have rendered to you However, you are responsible for following up to ensure the claim was filed within the proper time frame as noted below For services from an out-of-network provider, it is your responsibility to make sure you have received the necessary authorization from Aetna before receiving services or within 48 hours for emergency care It is also your responsibility to make sure the claim is filed correctly and on time, even if the out-of-network provider offers to assist you with the filing This means that you need to determine whether your claim is an urgent care (including concurrent care claim), pre-service, or post-service claim After you determine the type of claim, file the claim as noted below

The claim form is available at aetnanavigatorcom Or by calling Aetna at 1-888-802-4271 Claims for separate family members should be submitted separately If another insurance company pays your benefits first, submit a claim to that company first After you receive your benefit payment, submit a claim to Aetna and attach the other company's Explanation of Benefits statements along with your claim It is important to keep copies of all submissions Claims should be submitted to: Aetna Inc PO Box 981106 El Paso, TX 79998-1106 Complete information on filing claims can be found in the Benefits Book, "Appendix A: Claims and appeals"

Urgent care claims

If the Plan requires pre-service approval in order to receive benefits for care or treatment and a faster decision is required to avoid seriously jeopardizing the life or health of the claimant, contact Aetna at 1-888-802-4271 Important: Specifically state that your request is an urgent care claim

Claim questions, denied coverage, and appeals

If you have a question or concern about a benefit determination, you may contact Member Services before filing a formal appeal For more information, see the "Contacts" section on page 1 You may also file a formal appeal with Aetna without first informally contacting the Member Services department An appeal must be filed within 180 days of the date of the adverse determination of your initial claim regardless of any verbal discussions that have occurred regarding your claim Once you exhaust the internal appeals procedures, you are entitled to an external review of your claim

Aetna EPO Plan

Pre-service claims

If the Plan requires pre-service approval in order to receive benefits under the Plan, contact Aetna at 1-888-802-4271

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Complete information on appeals is provided in the Benefits Book, "Appendix A: Claims and appeals"

Coordination with other coverage

When you or your dependents have other group medical insurance (through your spouse's or domestic partner's employer, or Medicare, for example), the Wells Fargo health plan and the other plan may both pay a portion of covered expenses One plan is primary, the other plan is secondary This is called coordination of benefits (COB) Please note the following: · There is no COB between Wells Fargo health plans; only one Wells Fargo health plan will provide coverage for eligible expenses · Wells Fargo health plans do not coordinate prescription drug benefits For example, if you are covered under a Wells Fargo health plan and the other plan is primary, there is no secondary prescription drug benefit under the Wells Fargo health plan If the Wells Fargo health plan is secondary, it pays only the difference between the other plan's benefit, if lower, and the normal Wells Fargo health plan benefit When the primary plan pays a benefit that equals or exceeds the normal Wells Fargo health plan benefit, the Wells Fargo health plan pays nothing If you receive benefits from more than one group health plan (or a government-supported program other than Medicaid), the primary payer must process your claim before you can submit it to the secondary payer For detailed information regarding coordination of coverage, refer to the "Coordination with other coverage" section in "Chapter 1: An introduction to your benefits" of your Benefits Book

For purposes of this provision, a covered person includes anyone on whose behalf the Plan pays or provides any benefit including but not limited to the minor child or dependent of any plan member or person entitled to receive any benefits from the Plan

Subrogation Immediately upon paying or providing any benefit under the Plan, the Plan shall be subrogated to (stand in the place of) all rights of recovery a covered person has against any responsible party with respect to any payment made by the responsible party to a covered person due to a covered person's injury, illness, or condition to the full extent of benefits provided or to be provided by the Plan Reimbursement In addition, if a covered person receives any payment from any responsible party or insurance coverage as a result of an injury, illness, or condition, the Plan has the right to recover from, and be reimbursed by, the covered person for all amounts The Plan has paid and will pay as a result of that injury, illness, or condition from such payment up to and including the full amount the covered person receives from any responsible party Constructive trust By accepting benefits (whether the payment of such benefits is made to the covered person or made on behalf of the covered person to any provider) from the Plan, the covered person agrees that if he or she receives any payment from any responsible party as a result of an injury, illness, or condition, he or she will serve as a constructive trustee over the funds that constitute such payment Failure to hold such funds in trust will be deemed a breach of the covered person's fiduciary duty to the Plan Lien rights Further, the Plan will automatically have a lien to the extent of benefits paid by the Plan for the treatment of the injury, illness, or condition for which the responsible party is liable The lien shall be imposed upon any recovery whether by settlement, judgment, or otherwise, including from any insurance coverage, related to treatment for any injury, illness, or condition for which the Plan paid benefits The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the Plan including but not limited to the covered person; the covered person's representative, or agent; responsible party; responsible party's insurer, representative or agent; or any other source possessing funds representing the amount of benefits paid by the Plan

Subrogation and right of recovery provisions

Definitions

As used throughout this provision, the term "responsible party" means any party actually, possibly, or potentially responsible for making any payment to a covered person due to a covered person's injury, illness, or condition The term "responsible party" includes the liability insurer of such party or any insurance coverage For purposes of this provision, the term "insurance coverage" refers to any coverage providing medical expense coverage or liability coverage including but not limited to uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, medical payments coverage, workers compensation coverage, no-fault automobile insurance coverage, or any first-party insurance coverage

Aetna EPO Plan

31

First-priority claim By accepting benefits (whether the payment of such benefits is made to the covered person or made on behalf of the covered person to any provider) from the Plan, the covered person acknowledges that the Plan's recovery rights are a first-priority claim against all responsible parties and are to be paid to the Plan before any other claim for the covered person's damages The Plan shall be entitled to full reimbursement on a first-dollar basis from any responsible party's payments, even if such payment to the Plan will result in a recovery to the covered person that is insufficient to make the covered person whole or to compensate the covered person in part or in whole for the damages sustained The Plan is not required to participate in or pay court costs or attorney fees to any attorney hired by the covered person to pursue the covered person's damage claim

failure to assist the Plan in pursuit of its subrogation rights, or failure to reimburse the Plan from any settlement or recovery obtained by the covered person may result in the termination of health benefits for the covered person or the institution of court proceedings against the covered person The covered person shall do nothing to prejudice the Plan's subrogation or recovery interest, or to prejudice the Plan's ability to enforce the terms of this plan provision This includes but is not limited to refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the Plan The covered person acknowledges that the Plan has the right to conduct an investigation regarding the injury, illness, or condition to identify any responsible party The Plan reserves the right to notify the responsible party and his or her agents of its lien Agents include but are not limited to insurance companies and attorneys

Applicability to all settlements and judgments

The terms of this entire subrogation and right of recovery provision shall apply, and the Plan is entitled to full recovery regardless of whether any liability for payment is admitted by any responsible party and regardless of whether the settlement or judgment received by the covered person identifies the medical benefits the Plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses The Plan is entitled to recover from any and all settlements or judgments, even those designated as pain and suffering, noneconomic damages and/or general damages only

Interpretation

In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous, or questions arise concerning the meaning or intent of any of its terms, the claims administrator for the Plan shall have the sole authority and discretion to resolve all disputes regarding the interpretation of this provision

Jurisdiction

By accepting benefits (whether the payment of such benefits is made to the covered person or made on behalf of the covered person to any provider) from the Plan, the covered person agrees that any court proceeding with respect to this provision may be brought in any court of competent jurisdiction as the Plan may elect By accepting such benefits, the covered person hereby submits to each such jurisdiction, waiving whatever rights may correspond to him or her by reason of his or her present or future domicile

Cooperation

The covered person shall fully cooperate with the Plan's efforts to recover its benefits paid It is the duty of the covered person to notify the Plan within 30 days of the date when any notice is given to any party, including an insurance company or attorney, of the covered person's intention to pursue or investigate a claim to recover damages or obtain compensation due to injury, illness, or condition sustained by the covered person The covered person and his or her agents shall provide all information requested by the Plan, the claims administrator, or its representative, including but not limited to completing and submitting any applications or other forms or statements as the Plan may reasonably request Failure to provide this information,

32

Aetna EPO Plan

Chapter 3

Prescription drug benefit

The basics

CVS Caremark administers the prescription drug benefits offered under the Plan This means that when you select from CVS Caremark's Primary/Preferred Drug List, often referred to as a formulary, you'll save money The drugs on this list were chosen because they've been shown to work well in clinical trials and are cost effective Coverage is determined based on the established criteria for the prescription drug plan Not all medications are covered by the Plan (even if other medications in the same therapeutic class are covered) To obtain information on the established criteria, or to find out if your drug is on the Primary/Preferred Drug List, is covered by the Plan, or is subject to certain Plan provisions, visit caremarkcom or call Customer Care at 1-800-772-2301 to obtain information about this Plan's prescription drug coverage If you use a nonparticipating retail pharmacy, you'll be asked to pay 100% of the prescription price at the pharmacy and then submit a paper claim form with the original prescription receipt(s) to CVS Caremark If it's a covered expense, CVS Caremark will reimburse you as shown in the "What you'll pay for prescriptions" table on page 35, up to a 30-day supply per prescription To locate a CVS Caremark participating pharmacy: · Visit CVS Caremark's website at caremarkcom · Call Customer Care at 1-800-772-2301 · Ask your retail pharmacy if it participates in the CVS Caremark Retail Program

Filling your prescription

You can have your prescriptions filled at any retail pharmacy, but you'll save money if you use a pharmacy that participates in the CVS Caremark Retail Program Most national and regional retail pharmacies do When you have a prescription filled at a participating pharmacy, you can take advantage of the discounted network rates and you'll typically pay less than if you have a prescription filled at a nonparticipating pharmacy And remember, you'll save even more if you choose a drug from the Primary/Preferred Drug List or use CVS Caremark Mail Service Pharmacy

CVS Caremark Mail Service Use CVS Caremark Mail Service for prescriptions that you take on a regular basis, such as cholesterollowering drugs or birth control pills You can order up to a 90-day supply of your prescription through this service -- just be sure to ask your doctor to write a prescription for a 90-day supply of each medication, plus refills up to one year, if appropriate For example, ask your doctor to write a prescription for a 90-day supply with three refills, not a 30-day supply with 11 refills CVS Caremark will process all mail order claims received; prescriptions will not be held to be filled at a future date unless specifically requested

With CVS Caremark Mail Service you get: · Up to a 90-day supply of covered drugs for one copay · Access to registered pharmacists 24 hours a day, 7 days a week · Ability to refill orders online, by phone, or by mail -- anytime day or night · Free standard shipping

Retail pharmacies You can get up to a 30-day supply of most prescriptions at a retail pharmacy Exceptions include self-injectables, drugs that require special handling, and oral chemotherapy drugs See the "CVS Caremark Specialty Pharmacy" section on page 36 for more information

Bring your CVS Caremark ID card and pay your portion, as shown in the "What you'll pay for prescriptions" table on page 35, for up to a 30-day supply of each prescription Some drugs require prior authorization, so be sure to review the "Some prescriptions may require prior authorization" section on page 36 before filling a prescription for the first time

Ordering prescriptions Once you have filled a prescription through CVS Caremark, you can order refills by mail in three ways You should order your refill 14 days before your current prescription runs out Suggested refill dates will be included on the prescription label you receive from CVS Caremark

Aetna EPO Plan

33

Three ways to order prescriptions: · Online Go to caremarkcom If you are a first-time visitor, you'll need to register using your CVS Caremark ID number (shown on your CVS Caremark ID card) This is the most convenient way to order refills and inquire about the status of your order any time of the day or night · By phone ­ For existing prescriptions: Call Customer Care at 1-800-772-2301 for fully automated refill service Have your CVS Caremark ID number ready ­ For new prescriptions: Complete a mail service order form and send it to CVS Caremark along with your prescription · By mail Attach the refill label provided with your last order to a mail service order form Enclose payment with your order, if your plan requires a payment You can expect your medicine to arrive approximately 10 calendar days after CVS Caremark receives your prescription If you are currently taking a medication, be sure to have at least a 14-day supply on hand when you order If you don't have enough, ask your doctor to give you a second prescription for a 30-day supply and fill it at a participating retail pharmacy while your mail-order prescription is being processed Overnight or second-day delivery may be available in your area for an additional charge Your package will include a new mail service order form and an invoice, if applicable You will also receive the same type of information about your prescribed medicine that you would receive from a retail pharmacy

requires a prescription, subject to the exceptions listed in this chapter · Diabetic test strips, alcohol swabs, lancets · Insulin, insulin pen, insulin prefilled syringes, needles, and syringes for self-administered injections The list of preferred drugs, covered drugs, noncovered drugs, and coverage management programs and processes is subject to change As new drugs become available, they will be considered for coverage under the Plan as they are introduced

Diabetic supplies and medications You can purchase drugs and supplies to control your diabetes for one copay or coinsurance amount when you submit prescriptions for the diabetic supplies at the same time as your prescription for insulin or oral diabetes medication, or when you submit prescriptions for multiple insulins or oral diabetic medications, to CVS Caremark Mail Service Pharmacy Common diabetic supplies include lancets, test strips, alcohol swabs, and syringes or needles The copay or coinsurance amount you pay will depend on the type of diabetes medication prescribed

If you purchase diabetic supplies or diabetic medications at a retail pharmacy, separate copays or coinsurance amounts will apply to each item

What's covered

Covered prescriptions

In order for your prescription to be covered, it must meet CVS Caremark's coverage criteria In addition, all prescriptions are subject to the limitations, exclusions, and procedures described in this SPD When more than one definition or provision applies, the most restrictive applies and exclusions take precedence over general benefits descriptions The following prescription types are generally covered, but some may require prior approval, be limited in the amount you can get at any one time, or are limited by the age of the patient · Drugs that legally require a prescription, including compounded drugs where at least one ingredient

Primary/Preferred Drug List Certain prescription drugs are preferred because they help control rising prescription drug costs and are high-quality, effective drugs This list, sometimes called a formulary, includes a wide selection of generic and brand-name drugs The Primary/Preferred Drug List is reviewed and updated regularly by an independent pharmacy and therapeutics committee to ensure that it includes a wide range of effective generic and brand-name prescription drugs The list is continually revised to ensure that the most up-to-date information is taken into account Go to caremarkcom to see if your prescription is on the list Drug categories The Plan provides coverage for the following types of drugs:

· Generic prescription drugs Your most affordable prescription option The Food and Drug Administration (FDA) ensures that generic drugs meet the same standards for safety and effectiveness as their brand-name equivalents The brand name is simply the trade name used by the pharmaceutical company to advertise the prescription drug In the US, trademark laws do not

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Aetna EPO Plan

allow a generic drug to look exactly like the brand-

name drug Although colors, flavors, and certain

inactive ingredients may be different, generic drugs

must contain the same active ingredients as the

brand-name drug

· Preferred brand-name drugs Brand-name prescription drugs that are on the Primary/Preferred Drug List These drugs may or may not have generic

equivalents available

· Nonpreferred brand-name drugs Brand-name prescription drugs that are covered, but are not on the Primary/Preferred Drug List Because effective and less costly generic or preferred

brand-name drugs are available, you'll pay more

for these drugs However, they are covered under

the Plan

What you'll pay for prescriptions

Here's a snapshot of what you'll pay depending on the type of drug and where you get it Type of drug Network retail pharmacy Out-of-network retail pharmacy

You pay a $5 copay

(up to a 30-day supply) Generic drugs You pay a $5 copay

(up to a 30-day supply)

CVS Caremark Mail Service

(up to a 90-day supply) You pay a $10 copay

+

(full cost ­ CVS Caremark discounted amount) Preferred brand-name drugs You pay 30% of covered charges with $60 maximum per prescription You pay 30% of covered charges with $60 maximum per prescription You pay 30% of covered charges with $90 maximum per prescription

+

(full cost ­ CVS Caremark discounted amount) Nonpreferred brand-name drugs You pay 40% of covered charges with $90 maximum per prescription You pay 40% of covered charges with $90 maximum per prescription (full cost ­ CVS Caremark discounted amount) Maximum annual out of pocket for prescriptions NA NA $1,000 per individual and $2,000 per family -- mail only You pay 40% of covered charges with $140 maximum per prescription

Aetna EPO Plan

35

The following Plan provisions also apply to all prescription drug claims processing: · It's standard practice in most pharmacies (and, in some states, a legal requirement) to substitute generic equivalents for brand-name drugs whenever possible · If you purchase a brand-name drug when a generic equivalent is available, you will pay the generic copayment, plus the difference in cost between the brand-name drug and the generic drug Any difference in cost between the brand and generic is not applied to any maximum per prescription amount listed above At mail order, the difference in cost that you pay is not applied to the annual out-of-pocket maximum If your doctor requests the brand-name drug (ie, because it is medically necessary), you will pay the nonpreferred brand-name drug coinsurance amount · There are no exceptions to any of the copay or coinsurance amounts listed above, even with a physician's request For example, if the drugs on the preferred list are not appropriate for you, and you choose a drug that's not on the list, you will still have to pay the higher copay or coinsurance amount · Prescriptions for certain specialty drugs (typically self-injectables) cannot be filled at retail pharmacies For more information, see the "CVS Caremark Specialty Pharmacy" section on this page · CVS Caremark Mail Service is the only approved mail-order provider Any drugs ordered by mail from another provider will not be covered · Certain prescriptions have quantity limits Talk to your pharmacist if you have questions about possible quantity limits for your prescriptions · You'll need to get prior approval from CVS Caremark for certain prescriptions For more information, see the "Some prescriptions may require prior authorization" section on this page

CVS Caremark Specialty Pharmacy

Complex conditions such as anemia, hepatitis C, multiple sclerosis, asthma, growth hormone deficiency, and rheumatoid arthritis are treated with specialty drugs These are typically drugs that are self-injectable or require special handling, or oral chemotherapy drugs CVS Caremark Specialty Pharmacy is a comprehensive pharmacy program that provides these products directly to covered individuals along with supplies, equipment, and care coordination Contact CaremarkConnect toll-free at 1-800-237-2767 to get: · Personal attention from experts · Expedited, confidential delivery to the location of your choice · Pharmacist-led or nurse-led CareTeam to provide customized care, counseling on how to best manage your condition, patient education, and evaluations to assess your progress on therapy, and to discuss your concerns and help you achieve the best results · Pharmacists who are available 24 hours a day for emergency consultations · Coordination of home care and other health care services

Some prescriptions may require prior authorization

With most of your prescriptions, no prior authorization is necessary However, sometimes doctors write prescriptions that are "off label" (meaning not for the purpose the drug is normally used for) or for an out-of-the-ordinary quantity, or for some other flag that triggers a need for a review When you receive a prescription, simply take it to your retail pharmacy or send it to your CVS Caremark Mail Service Pharmacy as described in this chapter If prior authorization is necessary, your pharmacist or CVS Caremark will let you know If it's determined that prior authorization is necessary, the provider who prescribed the medication must call 1-800-626-3046 to verify pertinent information necessary for a prior authorization After the review is complete, CVS Caremark will send you and your doctor a letter confirming whether coverage has been approved (usually within 48 hours after CVS Caremark receives the information it needs) If coverage is approved, you'll pay your normal copay or coinsurance amount for your prescription If coverage is not approved, you will be responsible for the full cost

Your ID card

Shortly after you enroll in this Plan, you'll receive an ID card from CVS Caremark You'll need to present your ID card each time you purchase prescription drugs at a participating pharmacy If you do not have your ID card with you, you can pay for your prescription up front and file a claim for reimbursement You can also go to caremarkcom to print a temporary ID card

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of the medication Please note that prescriptions may fall under one or more coverage review programs If coverage is denied, you have the right to appeal the decision Information about the appeal process will be included in the notification letter you receive The lists of drugs that require prior authorization are subject to change at any time as new prescription drugs, generic drugs, or additional information about existing drugs become available Below are some examples of drugs that may require prior authorization: · Anabolic steroids (eg, Anadrol-50®, Winstrol®, Oxandrolone®) · Antimalarial agents (eg, Qualaquin®) · Botulinum toxins (eg, Botox® or Myobloc®) · Dermatologic agents (eg, Retin-A, Tazorac® or Solydyn®) · Erythoid stimulants (eg, Epogen®, Procrit®, or Aranesp®) · Growth stimulating agents (eg, Genetropin® or Norditropin®) · Immune globulines (eg, Vivaglobin®) · Interferon agents (eg, Intron® A, PegIntronTM, or Pegasys®) · RSV prevention injections (eg, Synagis®) · Multiple sclerosis therapy (eg, Avonex®, Betaseron®, or Copaxone®) · Narcolepsy treatments (eg, Provigil®, Nuvigil®) · Pain management (eg, Lidoderm® patches, Actiq, or Lyrica) · Cancer treaments (eg, Gleevec® or Avastin®) · Weight loss drugs (eg, Meridia®) · Other miscellaneous drugs (eg, Acthar® gel, Arcalyst®, Ilaris®, Kuvan®, Solaris®, or Xenazine®) Some drugs require what's called "step therapy" This means that a certain drug may not be covered unless you've first tried another drug or therapy Examples include: · Allergy medications You may need to try generic fexofenadine, or fexafenadine or pseudoephedrine before the Plan will cover Allegra D 24 hour®, Clarinex®, Clarinex D®, or Xyzal® · Blood pressure medications You may need to try generic benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, quinapril, ramipril, trandolapril, or Avapro® or Avalide® before the Plan will cover other brand name cardiovascular drugs such as Actacand®, Benicar®, Hyzaar®, Cozaar®, Diovan®, Micardis®, Tekturna®, or Teveten®

Aetna EPO Plan

· Migraine medications You may need to try generic sumatriptan (generic Imitrex®) or Relpax® before the Plan will cover other brand-name migraine medications such as Amerge®, Axert®, Frova®, Maxalt®, Migranal ND®, Treximet®, and Zomig® · Nasal steroids You may need to try generic flutocasone propionate (generic Flonase®), generic flunisolide (generic Nasarel®) before the Plan will cover other brand-name nasal inhaled steroid medications such as Beconase AQ®, Nasonex®, Omnaris®, Rhinocort AquaTM, or Veramyst® · Osteoporosis medications You may need to try alendronate (generic for Fosamax®) or Boniva® before the Plan will cover other brand-name osteoporosis medications such as Actonel® · Pain medications You may need to try generic ibuprofen, indomethacin, meloxicam, naproxen, or other generic nonsedating anti-inflammatory drugs before the plan will cover other brand-name drugs such as Athrotec®, Celebrex®, or Flector® · Proton pump inhibitors (PPIs) You may need to try generic omeprazole (generic Prilosec®) before the Plan will cover other brand-name PPIs such as Aciphex®, Prevacid®, Prilosec®, Protonix®, or Zegrid® · Sleep aids You may need to try generic zolpidem (generic Ambien®) before the Plan will cover other brand-name sleep aids such as Ambien CR®, Lunesta®, Rozerem®, and Sonata® For certain drugs, including the ones listed below, the Plan limits the quantity it'll cover However, a coverage review by CVS Caremark may be available to request additional quantities · Antiviral agents (such as Valtrex®, Zovirax®) · Antiemetic agents (such as Zofran®, Kytril®) · Migraine therapies (such as Imitrex®, Imitrex®NS, Zomig®, Zomig-ZMT®) · Oral bronchdilators (such as Albuterol®, Alupent®, Brethaire®, Maxaire®, Proventil®) · Oral inhaled steroids (such as Advair®, Aerobid®, Azmacort®, Beclovent®, Flovent®, Pulmicort®, Qvar®, Vanceril®) · Pain medications (such as Actiq®, Fentora®, Lyrica®) · Sleeping medications (such as zolpidem generic for Ambien®, Ambien CR®, Lunesta®, Rozerem®, Sonata®) Coverage review is not available for antifungal agents (eg, Sproanox®, Lamisil®, or Diflucan®)

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Prescriptions that are not covered

In addition to any other exclusions or limitations specified in Chapter 3 of this SPD, the Plan does not cover the following (even if prescribed by a physician): · Compounded drugs that do not meet the definition of compounded drugs; medications of which at least one ingredient is a drug that requires a prescription · Drugs or supplies that are not for your personal use or that of your covered dependent · Drugs or supplies prescribed to treat any conditions specifically excluded by the Plan · Drugs that are considered cosmetic agents or used solely for cosmetic purposes (eg, antiwrinkle drugs) · Drugs that treat hair loss, thinning hair, unwanted hair growth, or hair removal · Drugs that are already covered under any government programs, including Workers' Compensation, or medication furnished by any other drug or medical service that you do not have to pay for · Drugs that are not approved by the FDA, or that are not approved for the diagnosis for which they have been prescribed, unless otherwise approved by CVS Caremark based on clinical criteria as determined by CVS Caremark in its sole discretion · Investigational or experimental drugs, as determined by CVS Caremark in its discretion · Drugs whose intended use is illegal, unethical, imprudent, abusive, or otherwise improper · Early refills, except in certain emergency situations (eg, lost medication, traveling abroad) In these situations you may receive up to a 30-day supply at a retail pharmacy or a 90-day supply from CVS Caremark Mail Service If you are traveling abroad for more than 90 days, contact Customer Care at 1-800-772-2301 You'll be responsible for any copays or coinsurance amounts · Infertility drugs · Intrauterine devices (IUD) · Drugs you purchase outside the US that you are planning to use in the US · Drugs that require administration by a dental professional (eg, Arrestin, PerioChip) · Any drug used to enhance athletic performance · Over-the-counter drugs or supplies, including vitamins and minerals (except as may otherwise be required by applicable federal law)

· Nutritional supplements, dietary supplements, meal replacements, infant formula or formula food products · Prescriptions requested or processed after your coverage ends; you must be an active participant in the Plan at the time your prescription is processed -- not merely on the date your prescription is postmarked -- for your prescription to be covered · Prescriptions dispensed after one year from the original date of issue, more than six months after the date of issue for controlled substances, or if prohibited by applicable law or regulation · Prescription drug claims received beyond the 12-month timely filing requirement; CVS Caremark must receive claims within 12 months of the prescription drug dispensed date · Prescriptions that do not meet CVS Caremark's coverage criteria · Prescriptions that do not meet the Plan's definition of a covered health service · Prescriptions exceeding a reasonable quantity as determined by CVS Caremark in its discretion · Sexual dysfunction drugs · Topical antifungal polishes (eg, Penlac) · Mail-order prescriptions that are not filled at a CVS Caremark Mail Service facility The following are not covered as prescription drug benefits under the Plan; however, they may be eligible for some level of coverage under the Plan Please see Chapter 2 and contact Aetna for more information · Allergy sera or allergens · Contraceptive devices and inserts that require fitting or application in a doctor's office, such as a diaphragm, Depo-Provera, or Norplant · Injectable drugs that are not typically self-administered as determined by CVS Caremark in its discretion · Immunization agents or vaccines (except Zostavax® or Vivotif Berna) · Any drugs you are given at a doctor's office, hospital, extended care facility, or similar institution · Therapeutic devices, appliances, and durable medical equipment, except for glucose monitors This list is subject to change To determine if your prescription is covered, visit caremarkcom, sign on, and click Prescriptions and Coverage Or contact Customer Care at 1-800-772-2301

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Out-of-pocket maximums

If you use CVS Caremark Mail Service, you'll be subject to a $1,000 individual or $2,000 family out-of-pocket maximum However, there's no out-of-pocket maximum for retail pharmacy purchases

Prescription drug coordination of benefits

The prescription drug benefit under the Plan does not coordinate with other plans The Plan provides primary payment only and does not issue detailed receipts for submission to other carriers for secondary coverage If another insurance company, plan, or program pays your prescription benefit first, there will be no payments made under the Plan Because the Plan does not have a coordination of benefits provision for prescription drugs, you may not submit claims to CVS Caremark for reimbursement after any other payer has paid primary or has made the initial payment for the covered drugs If you or a covered dependent is covered under this Plan and Medicaid or other similar state programs for prescription drugs, in most instances, your prescription drug coverage under the Plan is your primary drug coverage You should purchase your prescription drugs using your CVS Caremark ID card and submit out-of-pocket copay expenses to Medicaid or other similar state programs

Your out-of-network claim will be processed faster if you follow the correct procedures Complete the Prescription Drug Reimbursement form and send it with the original prescription receipts You may not use cash register receipts or container labels from prescription drugs purchased at an out-of-network pharmacy Prescription drug bills must provide the following information: · Patient's full name · Prescription number and name of medication · Charge and date for each item purchased · Quantity of medication · Doctor's name To obtain a claim form: · Go to caremarkcom, log in, click Forms & Tools, and download the claim form · Call Customer Care at 1-800-772-2301 to request a form Send your claim to: CVS Caremark PO Box 52196 Phoenix, AZ 85072 You are responsible for any charges incurred but not covered by the Plan Please refer to "Appendix A: Claims and appeals" in your Benefits Book for more information regarding claims

Claims and appeals

Filing a prescription drug claim

Urgent care claims If the Plan requires preauthorization to receive benefits and a faster decision is required in order to avoid seriously jeopardizing the life or health of the claimant, fax your request to 1-888-836-0730

Important: Specifically state that your request is an urgent care claim

CVS Caremark claims questions, denied coverage, and appeals

If you have a question or concern about a claim already filed with CVS Caremark, you may contact Customer Care before requesting a formal appeal You may also file a formal appeal to CVS Caremark without first informally contacting Customer Care An appeal must be filed within 180 days from the date of the receipt of the initial denial, regardless of any verbal discussions that have occurred regarding your claim Once you exhaust the internal appeals procedures, you are entitled to an external review of your claim Complete information on appeals is provided in the Benefits Book, "Appendix A: Claims and appeals"

Pre-service claims If the Plan requires preauthorization in order to receive benefits, fax your pre-service claim request to 1-888-836-0730 Post-service claims You will need to file a claim if you buy prescription drugs or other covered supplies from a pharmacy not in the CVS Caremark network or if your network pharmacy was unable to submit the claim successfully All claims must be received by CVS Caremark within one year from the date the prescription drug or covered supplies were dispensed

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Other things you should know

Drug safety

The risks associated with drug-to-drug interactions and drug allergies can be very serious Whether you use CVS Caremark Mail Service or a participating retail pharmacy -- CVS Caremark checks for potential interactions and allergies CVS Caremark also sends this information electronically to participating retail pharmacies

Prescription drug rebates

CVS Caremark administers the prescription drug benefit on behalf of Wells Fargo, but because this Plan is self-insured, all claims are paid by the company through our claims and prescription drug administrators Drug manufacturers offer rebates for certain brand-name medications, the majority of which are on the Primary/Preferred Drug List If you purchase a rebate-eligible drug at a participating retail pharmacy or through CVS Caremark Mail Service, a portion of the rebate is passed on to you automatically at the point of sale The portion of the rebate passed on to you corresponds to your cost share of the drug The portion passed on to Wells Fargo corresponds to the cost share of the drug paid for by Wells Fargo Any rebates received by Wells Fargo are applied to the company's cost of providing and administering health care benefits

CVS Caremark may contact your doctor about your prescription

CVS Caremark can dispense a prescription only as it is written by a physician or other lawful prescriber (as applicable to CVS Caremark) Unless you or your doctor specifies otherwise, CVS Caremark dispenses your prescription with the generic equivalent when available and if permissible by law (as applicable to CVS Caremark) You're not limited to prescriptions on CVS Caremark's Primary/Preferred Drug List, but you will probably pay less if you choose a drug from that list If your doctor prescribes a drug that is not on the Primary/ Preferred Drug List but there's an alternative on the list, CVS Caremark may contact your doctor to see if that drug would work for you However, your doctor always makes the final decision regarding your prescriptions If your doctor agrees to use a preferred drug, you will never pay more than you would have for the original prescription, and will usually save money Also, CVS Caremark offers consultative services to help manage chronic or long-term conditions, such as diabetes These services may help you save on pharmacy costs and may help to prevent related complications or disease progression Through this program, you and your doctor may be contacted via telephone by a CVS Caremark pharmacist to discuss your therapy and provide condition and drug-specific counseling

Genetic testing for prescription drugs

With certain prescription drugs, genetic testing can assist with determining the optimal dose for an individual If you take one of these prescription drugs, you and your physician may be contacted to offer this testing Participation in the testing is voluntary and any changes to your dosing or medication would be at the sole discretion of your physician

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Chapter 4

Mental health and substance abuse benefits

If you enroll in the Aetna EPO Plan, you and your covered dependents have access to in-network mental health and substance abuse services as described in this chapter As always, it is between you and your provider to determine the treatments and procedures that best meet your needs The terms of this chapter control what, if any, benefits are available under the Aetna EPO Plan for mental health and substance abuse services you receive The fact that a provider has performed or prescribed a procedure or treatment, or the fact that it may be the only treatment for a particular injury, sickness, mental illness, or pregnancy, does not mean that it is a covered health service as defined by the Plan The definition of a covered mental health and substance abuse service under the Plan relates only to what is covered and may differ from what your provider deems to be a necessary health service

Aetna Behavioral Health

Aetna Behavioral Health is the claims administrator for mental health and substance abuse benefits described in this chapter, and provides confidential referrals for managed mental health and substance abuse care The Aetna Behavioral Health network includes psychiatrists, psychologists, master's level licensed therapists, and psychiatric nurses The Aetna Behavioral Health Clinical Referral Line is staffed 24 hours a day, 365 days a year For more information, see the "Contacts" section on page 1 To receive benefits through Aetna Behavioral Health, you must use an Aetna Behavioral Health provider in the network and you must follow the process described in this chapter

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Your benefits and costs at a glance

The information in the following tables is subject to the limits and exclusions noted in this chapter To identify providers who participate in the network, access the Provider Directory Service through Teamworks or at geoaccesscom/directoriesonline/wf If online access is not available, you may request a personalized directory by phone (See the "Contacts" section on page 1) Plan features: Aetna EPO

Annual deductible Annual coinsurance maximum (this amount is combined with medical) Mental health lifetime maximum Substance abuse lifetime maximum Mental health Outpatient Inpatient Partial hospitalization Substance abuse Outpatient Structured outpatient Inpatient Partial hospitalization

For preauthorization, contact Aetna at 1-888-802-4271

You pay in-network

Individual: None Family: None Individual: $2,500 Family: $5,000 None None

$25 copay per visit or $10 copay per group session, or $10 copay for medication management 10% of eligible covered expenses 10% of eligible covered expenses

$25 copay per visit or $10 copay per group session, or $10 copay for medication management 10% of eligible covered expenses 10% of eligible covered expenses 10% of eligible covered expenses

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Aetna EPO Plan

Mental Health and Substance Abuse Plan benefits

You can discuss your mental health or substance abuse needs in confidence or seek outpatient treatment referrals by calling either Employee Assistance Consulting (EAC) or Aetna Behavioral Health When you call the EAC or Aetna Behavioral Health and it's not an emergency, they will give you the name, address, and telephone number of one or more network providers in your area so you can make an initial appointment For treatment to be a covered health service, Aetna Behavioral Health must determine that the treatment is medically necessary, based on the Aetna Behavioral Health coverage criteria guidelines

Inpatient care, partial hospitalizations, and outpatient treatment must be precertified by Aetna Refer to the "Pre-service authorization required" section on page 44 for more information about precertification

Partial confinement treatment You pay 10% of eligible covered expenses Covered expenses include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of a mental disorder Such benefits are payable if your condition requires services that are only available in a partial confinement treatment setting

Inpatient care, partial hospitalizations and outpatient treatment must be precertified by Aetna Refer to the "Pre-service authorization required" section on page 44 for more information about precertification

Treatment of mental disorders and substance abuse

Treatment of mental disorders

Covered expenses include charges made for the treatment of mental disorders by behavioral health providers Important: Not all types of services are covered For example, educational services and certain types of therapies are not covered In addition to meeting all other conditions for coverage, the treatment must meet the following criteria: · There is a written treatment plan prescribed and supervised by a behavioral health provider · This Plan includes follow-up treatment · This Plan is for a condition that can favorably be changed Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility, or behavioral health provider's office for the treatment of mental disorders as described in the following sections

Outpatient treatment You pay $25 copay per visit of eligible covered expenses Covered expenses include charges for treatment received while not confined as a full-time inpatient in a hospital, psychiatric hospital, or residential treatment facility

The Plan covers partial hospitalization services (more than four hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment The partial hospitalization will only be covered if you would need inpatient care if you were not admitted to this type of facility Inpatient care, partial hospitalizations, and outpatient treatment must be precertified by Aetna Refer to the "Pre-service authorization required" section on page 44 for more information about precertification Additionally, refer to the "Your benefits and costs at a glance" chart on page 42 for any copays or deductibles, maximums, and payment limit that may apply to your mental disorders benefits

Treatment of substance abuse

Covered expenses include charges made for the treatment of substance abuse by behavioral health providers Not all types of services are covered For example, educational services and certain types of therapies are not covered

Inpatient treatment You pay 10% of eligible covered expenses Covered expenses include charges for room and board at the semiprivate room rate, and other services and supplies provided during your stay in a hospital, psychiatric hospital, or residential treatment facility Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting

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Substance abuse In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:

· There is a program of therapy prescribed and supervised by a behavioral health provider · The program of therapy includes either: ­ A follow-up program directed by a behavioral health provider on at least a monthly basis ­ Meetings at least twice a month with an organization devoted to the treatment of alcoholism or substance abuse Please refer to the "Your benefits and costs at a glance" chart on page 42 for any substance abuse deductibles, maximums, and payment limit that may apply to your substance abuse benefits

Inpatient treatment, partial-hospitalization care, and outpatient treatment must be precertified by Aetna Refer to the "Preservice authorization required" section on this page for more information about precertification

Partial confinement treatment You pay 10% of eligible covered expenses Covered expenses include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of substance abuse

Benefits are payable if your condition requires services that are only available in a partial confinement treatment setting Important reminders · Inpatient care, partial hospitalizations, and outpatient treatment must be precertified by Aetna Refer to the "Pre-service authorization required" section on this page for more information about precertification · Please refer to the "Your benefits and costs at a glance" chart on page 42 for any copayments, deductibles, maximums, and payment limit that may apply to your substance abuse benefits

Inpatient treatment You pay 10% of eligible covered expenses This Plan covers room and board at the semiprivate room rate and other services and supplies provided during your stay in a psychiatric hospital or residential treatment facility, appropriately licensed by the state Department of Health or its equivalent

Coverage includes: · Treatment in a hospital for the medical complications of substance abuse · "Medical complications" include detoxification, electrolyte imbalances, malnutrition, cirrhosis of the liver, delirium tremens, and hepatitis · Treatment in a hospital is covered only when the hospital does not have a separate treatment facility section Inpatient care, partial hospitalizations, and outpatient treatment must be precertified by Aetna Refer to the "Preservice authorization required" section on this page for more information about precertification

Pre-service authorization required

To receive benefits, you must use Aetna's network of providers under the Aetna Behavioral Health Plan If you do not use Aetna's Behavioral Health Plan network of providers, services are not covered except in emergency situations However, in rare cases, Aetna may provide authorization for you to receive nonemergency services from a nonnetwork provider Contact Aetna prior to receiving services to receive authorization The services listed below also require pre-service authorization in order to receive benefits under the Plan It is the responsibility of your network provider to contact Aetna Behavioral Health to pre-authorize services The member will not be penalized for not obtaining preauthorization For preauthorization, your provider will contact Aetna Behavioral Health at 1-888-802-4271 Any authorization is limited to a specific number of services for a specific period of time If additional services are needed, you will need to obtain a new authorization before receiving those services Refer to the "Pre-service claim" section in "Appendix A: Claims and appeals" in your Benefits Book for more information · Inpatient treatment · Out-of-network substance abuse care · Residential treatment centers (RTC)

Outpatient treatment You pay $25 copay per visit of eligible covered expenses Outpatient treatment includes charges for treatment received substance abuse while not confined as a full-time inpatient in a hospital, psychiatric hospital, or residential treatment facility

This Plan covers partial hospitalization services (more than four hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of alcohol or drug abuse The partial hospitalization will only be covered if you would need inpatient treatment if you were not admitted to this type of facility

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· Partial hospitalization · Intensive outpatient treatment · Structured outpatient treatment · Autism treatment · Inpatient admissions treatment · Partial Hospitalization Programs (PHPs) · Intensive Outpatient Programs (IOPs) · Psychological testing · Neuropsychological testing · Outpatient Electroconvulsive Therapy (ECT) · Biofeedback · Amytal interview · Psychiatric home care services · Outpatient detoxification · Applied Behavioral Analysis (ABA) Partial Hospital or Day Program is an outpatient level of care focused on psychiatric, eating disorder, and substance abuse care It is generally limited to no less than four hours per day and includes individual, group, family, and adjunctive therapies The program is either a day or evening program and is licensed by a regulatory authority Care is frequently used as a step-down from inpatient care or as an alternative to inpatient or more intensive level of care In addition to group individual and family therapies, the services may include special education, parent training, vocational training, skill building, crisis intervention, and recreational therapy Care is under the direction of a psychiatrist and the patient is seen by the psychiatrist at a regular interval, and frequency is dependent on the clinical needs Intensive Outpatient Program is an outpatient level of care focused on psychiatric, eating disorder, and substance abuse care The Care is delivered in a planned and structured program of at least two hours of treatment per day or six hours of treatment weekly Treatment modalities generally include individual, group, family, psycho educational, and adjunctive therapies as well as medication monitoring The program can address either mental or substance abuse issues Care is under the direction of a psychiatrist and the patient is seen by the psychiatrist dependent on the clinical needs

Continuing review for hospitalization

While you are in the hospital, Aetna Behavioral Health will continue to review the medical necessity of your stay and treatment

Residential treatment programs

You pay 10% of covered eligible expenses Expenses for care received in residential treatment programs are eligible for coverage if the facility meets Aetna credentialing requirements, is licensed by the state in which care is provided, and at the residential level, intermediate level or as an intermediate acute facility (ICF) in order to be considered eligible under the Plan RTC is defined as a 24-hour level of care that provides participants with long-term or severe behavioral or substance abuse disorders with residential care This care must be medically monitored with 24-hour medical availability and 24-hour on-site educated mental health or substance abuse specialists who are trained in responding to emergency situations Admission to a residential treatment center is not intended for use solely as a long-term solution or to maintain the stabilization acquired during treatment in a residential facility or program

Residential treatment facility (mental health and substance abuse) A residential treatment facility is a licensed institution that provides care 24 hours a day, 7 days a week, and meets all of the following requirements:

· Provides a comprehensive patient assessment (preferably before admission, but at least upon admission) · Provides access to necessary medical services 24 hours a day, 7 days a week · Provides living arrangements that foster community living and peer interaction that are consistent with developmental needs · Offers group therapy sessions with at least an RN or Masters-Level Health Professional · Has the ability to involve family and support systems in therapy (required for children and adolescents; encouraged for adults) · Provides access to at least weekly sessions with a psychiatrist or psychologist for individual psychotherapy · Has peer-oriented activities

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· Provides services managed by a licensed Behavioral Health Provider who, while not needing to be individually contracted, needs to: ­ Meet the Aetna credentialing criteria as an

individual practitioner

­ Function under the direction and supervision of a licensed psychiatrist (Medical Director) · Has individualized active treatment plan directed toward the alleviation of the impairment that caused the admission · Provides a level of skilled intervention consistent with patient risk · Meets any and all applicable licensing standards established by the jurisdiction in which it is located · Is not a Wilderness Treatment Program or any such related or similar program, school, or education service · Has the ability to assess and recognize withdrawal complications that threaten life or bodily functions and to obtain needed services either on-site or externally To receive benefits, you must be admitted by a physician Additional substance abuse treatment facility requirements include: · For member detoxification services, the residential treatment facility must have the availability of on-site medical treatment 24 hours a day, 7 days a week and must be actively supervised by an attending physician · 24 hours a day, 7 days a week supervision by a physician with evidence of close and frequent observation · On-site, licensed Behavioral Health Providers and medical or substance abuse professionals 24 hours a day, 7 days a week

be resolved by a psychiatric or diagnostic interview, observation in therapy, or an assessment for level of care at a mental health or substance abuse facility · Testing is needed to develop treatment recommendations after the member has been tried on various medications, psychotherapy, or both, has not progressed in treatment, and continues to be symptomatic Testing is not covered to diagnose or rule out: · Attention Deficit Disorder (ADD) · Attention Deficit/Hyperactivity Disorder (ADHD) · Learning disorder or disability

Autism coverage

You pay $25 copay per visit With Aetna Behavioral Health preauthorization, the autism benefit provides coverage for Intensive Behavioral Therapies (IBT) for team members and dependents with autism and autism spectrum disorders Each case will be reviewed, each diagnosis will be validated, and each treatment plan will be evaluated for appropriateness Aetna Behavioral Health level of care standards shall be applied The Plan covers IBTs, including applied behavioral analysis (ABA) and Repetitive Behavioral Intervention (RBI) that has been preauthorized by Aetna Behavioral Health

What is not covered

In addition to any other exclusions and limitations specified in this chapter, the following are not covered as mental health or substance abuse benefits under the Plan Some services may be eligible for some level of coverage under the Plan Please see Chapters 2 and 3 for more information about services and prescription drugs that may be covered by the Plan · The Plan will not pay benefits for any other services, treatments, items, or supplies, other than IBT, ABA, or RBI as defined by the Plan, even if recommended or prescribed by a physician, or if it is the only available treatment for autistic conditions · Behavioral health coverage for the autism benefit excludes tuition to publicly funded school-based programs for Pervasive Developmental Disorder (PDD) or any services provided by noneligible providers · Chelation therapy · Vocational rehab

Psychological and neuropsychological testing

You pay $25 copay per office visit Aetna Behavioral Health considers neuropsychological (NPT) or psychological testing (PT) medically necessary when needed to enhance psychiatric or psychotherapeutic treatment outcomes after a detailed diagnostic evaluation if: · Testing is needed to aid in the differential diagnosis of behavioral or psychiatric conditions when the member's history and symptomatology are not readily attributable to a particular psychiatric diagnosis and the questions to be answered by testing could not

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Aetna EPO Plan

· Educational services · Dolphin therapy · Equine therapy · Recreational therapy · Academic education during residential treatment · Aversion therapy · Care that does not meet the Aetna Behavioral Health coverage criteria guidelines · Court-ordered psychiatric or substance abuse evaluation, treatment, or psychological testing -- unless Aetna Behavioral Health determines that such services are medically necessary for the treatment of a DSM-IV mental disorder · Custodial care, regardless of the setting in which such services are provided Custodial care is defined as services that do not require special skills or training, and that either: ­ Provide assistance in activities of daily living (including but not limited to feeding, dressing, bathing, ostomy care, incontinence care, checking of routine vital signs, transferring, and ambulating) ­ Do not require continued administration by trained medical personnel in order to be delivered safely and effectively · Services for or related to educational testing, rehabilitation, or learning disabilities (except as listed as covered elsewhere in this SPD) · Experimental or investigational therapies as determined by Aetna Behavioral Health Generally, health care supplies, treatments, procedures, drug therapies, or devices that are determined to be any of the following: ­ Not generally accepted by informed health care professionals in the US as effective in treating the condition, illness, or diagnosis for which their use is proposed ­ Not proven by scientific evidence to be effective

in treating the condition, illness, or diagnosis for

which their use is proposed

­ Undergoing scientific study to determine safety

and efficacy

· Non-abstinence-based or nutritionally based substance abuse treatment · Charges for missed appointments, room or facility reservations, completion of claim forms, or record processing

· Services performed by a provider who is a family member by birth or marriage, including spouse, brother, sister, parent, or child, including any service the provider may perform on him- or herself · Services performed by a provider with your same legal residence · Claims filed more than 12 months from the date of service · Services received after the date your coverage under the Plan ends, including services for conditions arising or under treatment before your coverage ends · Interest or late fees charged due to untimely payment for services · Out-of-network services, unless approved by Aetna · Private duty nursing (see the "Extended skilled nursing care" section on page 18 for more information) · Psychiatric or psychological examinations, testing, or treatment that Aetna Behavioral Health determines is not medically necessary, but which nevertheless may be required for purposes of obtaining or maintaining employment or insurance, or pursuant to judicial or administrative proceedings · Psychological or neuropsychological testing that has not been preauthorized by Aetna Behavioral Health · State hospital treatment, except when determined by Aetna Behavioral Health to be medically necessary · Therapies that do not meet national standards for mental health professional practice: for example, primal therapy, bioenergetic therapy, crystal healing therapy, rolfing, megavitamin therapy, or vision perception training · Treatment for personal or professional growth, development, or training, or professional certification · Treatment for stammering or stuttering, including that to maintain employment or insurance · Treatment not provided by an independently licensed psychiatrist, psychologist, or master-level mental health provider · Treatment of chronic pain, except when rendered in connection with treatment of a DSM-IV mental disorder · Treatment of a covered health care provider who specializes in the mental health care field and who receives treatment as a part of their training in that field

Aetna EPO Plan

47

· Treatment of impulse control disorders such as pathological gambling, kleptomania, pedophilia, or caffeine · Treatment of antisocial personality disorder · Treatment in wilderness programs or other similar programs · Educational services: ­ Any services or supplies related to education, training, or retraining services or testing, including special education, remedial education, job training, and job hardening programs ­ Evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental, learning and communication disorders, behavioral disorders, (including pervasive developmental disorders) training or cognitive rehabilitation, regardless of the underlying cause ­ Services, treatment, and educational testing and training related to behavioral (conduct) problems, learning disabilities, and delays in developing skills · Services that do not meet the criteria established in, or are excluded under, the Aetna Behavioral Health's mental health and substance abuse coverage policy guidelines

Claims and appeals

All claims must be filed within 12 months from the date of service If you use a network provider, the provider will file the claim for you, and Aetna Behavioral Health will pay the provider directly To obtain a claim form, call Aetna at 1-888-802-4271 or visit wfaetnaplancom If the provider files a claim on your behalf, you are still responsible for ensuring it is filed properly and within the required time frame More information on filing claims can be found in "Appendix A: Claims and appeals" in your Benefits Book

Mental health and substance abuse claim questions, denied coverage, and appeals

If you have questions or concerns about a claim already filed with Aetna, you may contact member services before filing an appeal with Aetna For more information, see the "Contacts" section on page 1 You may also file an appeal with Aetna without first informally contacting the Aetna member services department An appeal must be filed within 180 days of the date of the adverse determination of your initial claim regardless of any verbal discussions that have occurred regarding your claim Once you exhaust the internal appeals procedures, you are entitled to an external review of your claim Complete information on appeals is provided in the Benefits Book, "Appendix A: Claims and appeals"

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Aetna EPO Plan

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Aetna EPO Plan Summary Plan Description

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