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Your Aetna plan features,and how to sign up

Illinois Small Group Enrollment Guide

Health and life insurance plans/policies are offered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).

At Aetna, we are committed to putting you at the center of everything we do. You can count on us to provide member tools and value-added programs that enhance your member experience.

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Welcome to Aetna!

Whatever your healthy is, we can help you get there. Everyone’s healthy is different. For your family, how you define your healthy may include what’s healthy for your budget too. We understand that, and that’s why we provide multiple plans that can help you reach your healthy while keeping your financial health on track too.

With Aetna, you can choose the path that gets you closer to your healthy. Whether your goal is lower monthly premiums, lower out-of-pocket costs at doctor’s visits or easy access to out-of-network care, we have plans that will work hard for you.

We know that part of everyone’s healthy is knowing that you’re making smart choices when it comes to your health care. So we give you the power to do that at every step along the way. Find a doctor online, check the status of a claim and compare out-of-pocket costs before you go. Our tools and resources help make sure your family’s well-being is always well-coordinated. And you’ll have the right tools to manage your health care for a healthier you. Let’s work together to find your healthy.

Table of Contents Aetna Navigator® secure member website 4Health care transparency tools 5Personal Health Record 6Visit your doctor online 7Informed Health® 24-hour nurse line 8Employee Assistance Program (EAP) 8Urgent care 8Special programs for the special needs of women 9At-home products discounts 10Book discounts 10Fitness discounts 10Hearing discounts 11Natural products and services discounts 11Oral health care discounts 11Vision discounts 12Weight management discounts 12Preventive care 13Medical products 14Dental products 15Life insurance 16Disability insurance 16Prescription drug coverage 17Limitations and exclusions 19Find a doctor or specialist in the Aetna network 22How to complete the enrollment form application 24Your member ID card 26Contact information 27

4*If Included in your plan.

Aetna Navigator® secure member website

When you need up-to-date information about your health benefits and insurance plan or want information about a particular health condition, here’s where you’ll find it!

You can turn to your secure Aetna Navigator® member website, your single source for online health and benefits information. It’s convenient, and easy to use:

1. Go to www.aetna.com.

2. Click on Log In/Register.

3. Register as a new user, or log in using your secure user name and password.

4. Find a wealth of credible health care information and self-service functions — available to you anytime of the day or night — from wherever you have Internet access.

Your secure website lets you:

• View information about who is covered on your plan

• Find doctors, pharmacies or hospitals with our DocFind® search tool

• Check the status of a claim or review an Explanation of Benefits (EOB)

• Contact Member Services with benefits questions (also available in Spanish)

Use Aetna Navigator’s online tools to manage your benefits and help you make more informed health decisions:

• Hospital Comparison tool helps you decide where to receive care for specific procedures, conditions and diagnoses. You can compare hospitals based on four factors you consider important:

1. Number of patients treated per year

2. Complication rates

3. Mortality rates

4. Length of stay

• Price-A-DrugSM tool* helps you estimate the cost of prescriptions before you buy

• Estimate the Cost of Care tool provides average in-and out-of-network costs for certain procedures based on a geographic area

• Pharmacy tab allows you to locate retail pharmacies; order prescriptions through the Aetna Rx Home Delivery® mail-order pharmacy; search and learn about medications; and review the medications available in the Aetna preferred drug list (formulary)

And, if you’re interested in learning more about a particular health condition, Aetna Navigator provides credible health information resources.

• Simple Steps To A Healthier Life® interactive online health and wellness program can help you turn knowledge about your health into action for making positive health changes with:

- Online health assessment

- Tailored health reports

- Personalized action plan and online wellness programs

- Easy-to-find health information, resources and tools

• Aetna SmartSourceSM tool delivers relevant health information that’s specific to you, based on where you live, your Aetna health plan, and other information.

Aetna SmartSource scans our vast resources to bring you, in a single search:

- Specialists in your local area

- Related medications, treatment options and estimated health costs

- Aetna programs that may help you manage your condition

- Easy-to-understand health articles and tips

• Aetna InteliHealth® website helps you research credible health, dental and wellness information provided by Harvard Medical School

• Healthwise® Knowledgebase is a user-friendly online information tool that lets you research your own issues and preferences for health information

- Interactive and streaming videos about topics such as asthma and heart health

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* Always consult your doctor about your health care decisions. Members cannot view rates for dentists, vision providers or certain types of health care professionals with these tools.

** Clinical quality and efficiency information is based on Aexcel® designation for specialists in 12 specialty categories. You can learn more about our Aexcel designation in our Understanding Aexcel brochure available under the Learn More section of DocFind. We regularly upgrade our tools to provide the latest cost and clinical quality and efficiency information about our network providers.

Health care transparency tools

You can make more informed health care decisions by using our online transparency tools before visiting a doctor or hospital.*

Our transparency tools allow you to:

• View and compare rates for participating doctors.

• Look up costs for medical procedures at facilities in select locations around the country and quickly identify medical specialists who are high performers in their field based on clinical quality and efficiency.**

• Use at your convenience. The information is available 24/7 through your Aetna Navigator website, and in our DocFind® online directory of doctors and facilities.

To access our health care transparency tools, log in to Aetna Navigator. Click on Estimate the Cost of Care from the Care & Treatment tab. There, you can follow the easy online instructions to:

• Check rates for doctors and specialists for common treatments and procedures.

• Compare hospital costs side by side.

• Get personalized cost estimates to find out what you’ll pay before you go.

6* The Aetna Personal Health Record should not be used as the sole source of information about your health history.

Personal Health RecordPut your Personal Health Record to work and make history!

Your Personal Health Record* is a secure online tool that makes it easy to:

• Keep your health information in a single, safe place

• Track doctor visits, prescriptions and more, for you and your family

• Give your doctor a more complete health history

• Receive timely, personalized health alerts and preventive care reminders

Much of your health information is added for you

Information from your Aetna health claims automatically appear in your Personal Health Record. And, you can easily add more information. List your allergies, your family history and more. It’s up to you. The more you enter, the better picture you and your doctors will get of your overall health.

Use it to talk to your doctors with ease

The Personal Health Record can help you team up with your doctors. You can share your Personal Health Record online with individual doctors by making it available through a secure website many doctors already use. You also can print your Health Summary to share at office visits or to help you fill out medical forms when you see a new doctor.

Stay safe and healthy with alerts and reminders

Your Personal Health Record helps you get the care you need. If you’re due for a checkup or other important screening, you might see a reminder when you log in. You may also receive a message if there’s an alternative treatment that may improve your care. And, if you give us permission, you can get e-mails telling you that a new alert or reminder is in your secure Personal Health Record.

Your personal health records go where you go

Our relationship with Microsoft lets you take your personal health information with you. You can transfer a copy of your Aetna Personal Health Record from Aetna Navigator directly to Microsoft HealthVault at www.healthvault.com/personal. Your information will be stored on this secure, web-based consumer health platform and remains available if you change jobs or health plans.

You can also print and save a PDF copy of your health record for your own files through the same Aetna Navigator location.

Print your personalized emergency card

You can print an Emergency Information Card that pulls information from several sections of your Personal Health Record. It provides first responders with your emergency contact’s name and phone number, your insurance details, any medications you are taking, allergies if you have any, and information about whether you have a living will or have designated your organs for donation. All this detail in a printout that folds and fits in your wallet.

Be sure the information in these sections is accurate and up to date, and start using your Aetna Personal Health Record as soon as your Aetna health plan is active!

It’s easy to get started.

Visit your Personal Health Record or use our Walk Me Through guide to explore how this resource works on your own.

Visit www.aetna.com/showcase/phr/ for answers to the most common questions from our members.

7Check your service area for availability.

Programs to help you get the care you need

Visit your doctor online

RelayHealth® “webVisits” let you communicate effectively and securely online with your doctor for non-urgent medical care. You pay any required copays or deductibles through the system as if you had made an office visit.

webVisit is easy to use:

1. Enter the RelayHealth website for non-urgent medical care.

2. Complete a questionnaire.

3. Submit it directly and confidentially to your doctor.

4. Once your doctor reviews your questionnaire, you will get a diagnosis, instructions and information — just like at an actual visit.

Three great reasons to use RelayHealth instead of e-mail:• Secure and authenticated with user login

• Clinically structured questionnaire focuses on your symptoms to help your doctor determine an accurate diagnosis

• Checks plan eligibility in real time, collects copayment and submits claim automatically

How to get started:• Click the Register Now link on the RelayHealth website at

www.relayhealth.com/Patients/Registration.aspx

• Once registered, choose an Aetna contracted RelayHealth provider

Then log in at your convenience to take advantage of the many features available to registered members, in addition to the webVisit service:

• Consult with your doctor

• Make and/or cancel appointments

• Obtain referrals

• Request lab and test results

• Order prescription refills

• Send a note to your doctor’s office

webVisit through RelayHealth links you with your doctor, Aetna health plan and pharmacy in a single secure network.

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Programs to help you get the care you need

Informed Health® 24-hour nurse line

Access to a registered nurse — 24/7 With our Informed Health Line, you can talk to a registered nurse anytime, day or night. Just call our 24-hour toll-free number (anytime upon enrollment). While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on thousands of health topics. They can also help you ask the right questions and describe health symptoms more effectively during your next visit to your doctor. Remember, always contact your doctor first with any questions or concerns regarding your health care needs.

Employee Assistance Program (EAP)*

If included with your plan, our Employee Assistance Program gives you confidential access to useful services and support to help manage the everyday challenges of work and home. The EAP is available at no charge to you and your family members and includes:

Choice of resources to help balance your personal and professional lives.

Easy access to EAP representatives anytime toll free at 1-866-672-5417 or on the web at www.aetnaeap.com.

Professional assistance from workplace-trained specialists, who provide confidential phone support, assess needs and recommend an appropriate course of action. You get three phone consultations (per member) in a calendar year.

Urgent care

For care that is not minor, such as fractures, sprains or other urgent injuries, we contract with urgent care centers to offer you an economical alternative to visiting an emergency room. Urgent care sites are staffed with physicians to handle urgent medical needs. Typically, urgent care centers offer evening and weekend hours with no appointments needed.

Check your plan design and benefits summary to get more information about coverage and costs to visit an urgent care center. To find the closest care center near you, simply log in to Aetna Navigator, select DocFind and follow the easy online instructions.

* EAP is administered by Aetna Behavioral Health, LLC and Aetna Life Insurance Company.

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Special programs for the special needs of women

Ongoing health managementWork, family, friends. Too much to do, too little time to do it. That’s today’s woman. Add health needs that change over time, and you’ll know why we offer services and information to help you manage your health.

Prevention programs for womenOur preventive programs can help women benefit from:

• Preventive screening reminders for breast and cervical cancer

• Culturally focused initiatives to help reduce health disparities among women of diverse ethnic backgrounds

Women’s health onlineGo to http://womenshealth.aetna.com for information on women’s health issues — from heart health, breast cancer and pregnancy to baby care and other topics important to women, as well as:

• An interactive body mass index tool

• A pregnancy guide

• USDA Food Plate recommendations

• Information on diet and nutrition

For OB/GYN care, no referrals neededFor an annual well-woman exam, unlimited visits for gynecologic problems and routine maternity care, women may schedule an appointment with participating obstetrical, gynecological or women’s health care professionals without a referral.

Beginning Right® maternity programThe Beginning Right maternity program offers information and services to expectant mothers, including care coordination by obstetrical nurses experienced in preterm labor education, breastfeeding support and more. We want to make sure expectant mothers have the information needed to make informed decisions about health care while pregnant or planning a pregnancy. Members enrolled in both our medical and dental plans, along with our Beginning Right maternity program, may also receive enhanced dental benefits (additional cleaning or treatment of periodontal (gum) disease, fully covered with no deductible) during pregnancy.

Special maternity careFrom the start of pregnancy to birth, our maternity management program offers expectant mothers services and educational materials to help give their newborns a healthy start.

Moms-to-be receive:

• Educational materials, available in English or Spanish, that cover:

- Prenatal care

- Labor and delivery

- Newborn and baby care

- Breastfeeding

- Postpartum depression

• A pregnancy risk survey and nurse care coordination for high-risk pregnancies

• A program to help you stop smoking

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1Includes two or more books combined as a special discount package.2 Participation is for new gym members only. If you belong to a gym now, or belonged recently, call GlobalFit to see if a discount applies.

Member discounts

At-home products

You can get discounts on products for your home and family that best fit your needs and your life, such as Omron Healthcare, Inc. blood pressure monitors.

Books

You can save on books, DVDs, and more.

• American Cancer Society Bookstore offers discounts on books, greeting cards and kits.1 Order online or by phone.

• Mayo Clinic Bookstore lets you save on books and DVDs purchased online.

• Pranamaya includes savings on yoga DVDs, CDs, online videos and books.

Fitness

Regular exercise can help you maintain a healthy weight and look and feel better. It can also lower your risks for:

• Alzheimer’s disease

• Depression and anxiety

• Diabetes

• Heart disease

• High blood pressure

You can save on gym memberships2 and name-brand home fitness and nutrition products that support a healthy lifestyle with services provided by GlobalFit®.

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1 The ChooseHealthy program is made available through American Specialty Health Administrators, Inc., a subsidiary of American Specialty Health Incorporated (ASH). ChooseHealthy is a federally registered trademark of ASH and used with permission herein.2 Guideline on Xylitol Use in Caries Prevention. American Academy of Pediatric Dentistry, Council on Clinical Affairs. Vol. 35, No. 6. 2011. Available at: www.aapd.org/media/policies_guidelines/g_xylitoluse.pdf. Accessed March 18, 2014.

Hearing

You can take care of your hearing and save money with Hearing Care Solutions and HearPO®.

Hearing Care Solutions includes savings• A discounted rate on hearing exams

• Hundreds of hearing aid models at low prices

• A two-year supply of batteries (up to 96 cells), then join a discount battery mail-order program

• Free in-office service of hearing aids for one year after purchase

• Free routine services (cleanings, checks and battery door replacements) for the life of the hearing aid

HearPO includes:• A discounted rate on hearing exams

• Savings on many hearing aid styles

• A cost break on the newest hearing-aid technologies, including programmable and digital instruments from leading manufacturers

• Discounts on hearing aid repairs

• Free follow-up services for one year

• Free batteries (up to 160 cells per hearing aid)

Natural products and services

You and your family can save on specialty health care products and services, including online consultations.

The ChooseHealthy®1 program gives you a discount off the normal fee for acupuncture, chiropractic, massage therapy and nutrition services. And get a discount off the retail price of health and wellness products.

Vital Health Network lets you save on the retail price of an online consultation with a Vital Health Network doctor for one topic. Then, save more off the retail price of an online consultation for additional topics.

Oral health care

Taking care of your teeth is important. Who doesn’t enjoy a healthy smile and fresh breath?

You can take care of your teeth and save money on oral health care products from Epic Dental and Waterpik®.

Epic Dental lets you save on Epic Dental products that contain xylitol, a natural sweetener that does not cause cavities. In fact, xylitol has been shown to prevent tooth decay.2 Save on gum, mints, toothpaste and more.

Waterpik includes savings on oral health care products that help keep your mouth as healthy as it can be.

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1�You can cancel your program membership at any time during the first seven days. Log in to the program and follow the instructions in “Payment and Account Details” under “Account Settings.” If you do not cancel during the first seven days, your credit card will be charged on the eighth day. 2 If you are already a CalorieKing member and want to get the Aetna discounted membership price, you will need to terminate your current CalorieKing Account and rejoin.3�Plus the cost of food. Plus the cost of shipping (if applicable). Offers apply to initial enrollment fee only and are valid only at participating Centers and through Jenny Craig At Home. Each offer is a separate offer and can be used only once per member. No cash value. Restrictions apply.4 The Aetna discount offers do not apply to any plan in which you are already enrolled. To receive the discounted rate, you must wait until your current plan ends.

Vision

You can take care of your vision and save with EyeMed. Get discounts on:

• Eye exams

• Eyeglass frames and lenses

• Contact lenses and solutions

• LASIK surgery

• Sunglasses (prescription and nonprescription)

• And more!

Use any eye care provider in the EyeMed nationwide network, at the following retail chains:

• Lenscrafters®

• Pearle Vision®

• Target Optical®

• Sears Optical® locations

• JCPenney Optical

You also can use any of the thousands of participating eye doctors in private practices.

You can get these discounts even if you have other vision benefit coverage. If you do have coverage, check your plan requirements first.

Weight management

You can meet your weight loss goals, get healthier and save money on CalorieKing®, Jenny Craig® and Nutrisystem®.

CalorieKing lets you:

- Join an Annual or Monthly CalorieKing Program. Programs have a seven-day free trial period.1

- Then save when you continue your Annual Program membership.2

- With either an Annual or Monthly Program membership, you can also save on products in the CalorieKing online Store.

Jenny Craig allows you to choose from theses offers:

- FREE 30-Day Program3

- Percent off the Jenny All Access Program enrollment fee3

Nutrisystem includes:

- Savings on any 28-Day Nutrisystem® SuccessTM weight loss meal plan.4

- Plus, get other offers from Nutrisystem when you purchase a plan.

With all programs and plans, enjoy one-on-one help, personalized menus, online tools, chat rooms and more.

Visit your secure Aetna Navigator® member website at www.aetna.com for more details about all available discounts.

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* Not scored by Clinical Stratification and Identification (CSID) process.**Addressed as a comorbid condition.

Prevention programs — helping you and your family stay healthy

Preventive care

Good health begins with prevention. So we’ve developed an array of wellness programs and services to help you and your family stay healthy through all the stages of your life.

Member health education reminders

To help prevent, detect and monitor problems early on, we mail reminders encouraging you to schedule important annual health screenings. We also send important health information, a chart of recommended preventive care guidelines and a tear-off wallet card to schedule and track this important information.

Aetna Health ConnectionsSM disease management program

Our enhanced Disease Management program allows our nurses to support over 35 different ongoing health conditions.

Vascular• Heart failure

• Diabetes – adult & pediatric

• Coronary artery disease (CAD)

• Peripheral artery disease (PAD)

• High blood pressure – adult & pediatric

• Cerebrovascular disease/stroke (CVA)

• High cholesterol

Pulmonary• Asthma – adult & pediatric

• Chronic obstructive pulmonary disease (COPD)

Orthopedic/Rheumatologic• Osteoporosis

• Osteoarthritis (OA)*

• Rheumatoid arthritis (RA)

• Chronic lower back pain

Gastrointestinal• Gastro esophageal reflux

disease (GERD)

• Peptic ulcer disease

• Inflammatory bowel disease (IBD) (Crohn’s Disease)

• Chronic hepatitis

Neuro-Geriatric• Geriatrics

• Migraines

• Seizures

• Parkinsonism

Cancer• General cancer

• Breast cancer

• Lung cancer

• Lymphoma/Leukemia

• Prostate cancer

• Colorectal cancer

Renal• Chronic kidney disease

• End stage renal failure

Other• Weight management –

adult & pediatric

• Cystic fibrosis – adult & pediatric

• HIV

• Hypercoagulable state

• Sickle cell disease – adult & pediatric

• Depression**

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Medical productsPick the right health benefits and insurance plan for your family

Plan features HMO

Saving Plus HMO

PPO/OAMC

Saving Plus

OAMC

Coverage for preventive care • • • •

No PCP requirement • •

No referrals • •

Out-of-network access • •

No claim forms when in network • • • •

Affordability scale $$$ $$$ $$ $

Savings Plus Open Access® Managed Choice® (OAMC) The Savings Plus network is a subset of the Managed Choice (MC) network available in certain areas. As a Savings Plus member, you can access the same types of coverage as other OAMC plans, but at a lower premium costs. All non-emergency services performed outside of the Illinois Savings Plus Managed Choice network of doctors and hospitals will be paid at the out-of-network benefit level.

HMO Aetna Savings Plus planThe Aetna Savings Plus HMO plan gives you the same type of coverage as the Aetna HMO plans, but at a lower premium cost. Your costs are lower when you use the Savings Plus network, a quality network of local health care providers.

The Aetna provider network has more than 18,000 doctors and 104 hospitals in Illinois.* So whichever plan you choose, you will be able to find a health care provider to best suit your needs.

Use DocFind to search for a primary care physician (PCP) for your family.

www.aetna.com/docfind

Call the Member Services number on your ID card to order a printed provider directory.

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*All family members must be enrolled in the same plan.1 MayoClinic.com. “Oral health: A window to your overall health.” Available at www.mayoclinic.com/health/dental/DE00001. Accessed May 2010.2 R.C. Williams, A.H. Barnett, N. Claffey, M. Davis, R. Gadsby, M. Kellett, G.Y.H. Lip, and S. Thackray. “The potential impact of periodontal disease on general health: a consensus view.” Current Medical Research and Opinion, Vol. 24, No. 6, 2008, 1635-1643.

Dental productsPick the right dental benefits and insurance plan for your family*

A healthy body starts with a healthy smile

Research suggests that serious gum disease, known as periodontitis, may be associated with many health problems. This is especially true if serious gum disease continues without treatment.1,2

Now, here’s the good news. Researchers are discovering that a healthy mouth may be important to your overall health.1,2

Plan features DMO® PPO Freedom-of-Choice*

DMOFreedom-of-Choice*

PPO

Coverage for preventive care • • • •

No primary care dentist requirement • •

No referrals • •

Out-of-network access • •

No claim forms • •

No deductibles • •

No dollar annual maximums • •

Need to find a participating dentist? Just visit DocFind or give us a call.

www.aetna.com/docfind

1-877-238-6200

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Life and disability insurance

Protection for the future

Nothing is more reassuring than knowing financial resources are available when you need them most. Our products provide you and your dependents financial support when it counts. And, you’ll be glad to know that, with Aetna, you have access to life insurance from a company with more than 150 years of industry experience. Your financial future is in good hands.

Life insurance

The building block of financial security. Our life insurance plans come with a variety of features including:

Accelerated death benefit, or “living benefit,” lets you receive payment if you become terminally ill. This payment can be up to 75 percent of the life insurance benefit.

Premium waiver provision means your coverage may stay in effect up to the amended normal Social Security retirement age — without premium payments (unless you retire sooner) — if you become permanently and totally disabled while insured due to an illness or injury before age 60.

Aetna Life Essentials is a package of programs and resources available to you and your beneficiaries at no extra cost. The Aetna Life Essentials programs help you address health, wellness, financial and emotional needs during your life, as well as for those critical caring and support needs you and your loved ones may have at the end of your life and after you’ve passed away.

AD&D Ultra®

This progressive product provides you better financial security than typical accidental death and personal loss plans — and then some. That’s because AD&D Ultra includes coverage for education or dependent child care expenses upon the death of the insured.

Disability insurance

Did you know the ability to earn an income is the most important financial resource for you?

That is why disability insurance is so important.

We have experienced and caring professionals who understand the challenges of disability, and your need to be able to work.

Here are a few ways our disability plans protect you:

• Our embedded Behavioral Health Unit (BHU) has compassionate licensed therapists and psychiatric nurses who recognize the complexities of behavioral health conditions. They work with you and your health care providers to overcome barriers blocking successful return to work.

• Master’s level Vocational Rehabilitation Consultants offer a coordinated productivity approach centered on your abilities to aid your transition back to the workforce.

More choices for interaction

Our best-in-class technology offers more choices for you to interact with us. Whether you choose mail, phone, e-mail, mobile application or our convenient WorkAbility® Absence Management System online portal, information is available on your schedule, not ours.

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Claritin® is a registered trademark of Schering-Plough HealthCare Products Inc.Prilosec® is a registered trademark of AstraZeneca LLP.

Prescription drug coverage

Know what drugs are covered

You and your doctor can choose from hundreds of quality, cost-effective drugs. Your plan covers brand-name and generic drugs on the Aetna Pharmacy Plan Drug List. (You may also see this called a “formulary.”) It was developed based on advice from many different health care specialists. And all drugs on it are approved by the U.S. Food and Drug Administration (FDA).

Your plan also covers many drugs that are not on this list. Remember though, you’ll often pay less for drugs on our list.

To see this list or learn about medication alternatives, go to www.aetna.com/formulary.

Aetna Specialty Pharmacy® Services

A specialty pharmacy fills prescriptions for specialty drugs. These types of drugs may be injected, infused or taken by mouth. Usually you cannot get these drugs at a local retail pharmacy. They often need special storage and handling, they need to be delivered quickly and a nurse or pharmacist should check in with you often during your treatment.

You may get your first prescription filled at a retail pharmacy. After that, prescriptions must be filled through Aetna Specialty Care Pharmacy.

To learn more about Specialty Drugs go to www.AetnaSpecialtyRx.com or call 1-866-782-ASRX (1-866-782-2779).

Getting plan approval for certain medications

Some drugs need precertification before your plan will cover them. This simply means we need to approve them first for you. Doing this helps make sure the drug is being used at the right dose, for the right reasons. This helps keep you safe. It can also help you find another drug that costs less and is just as effective — something you could talk about with your doctor.

Your doctor will contact us by phone, fax or e-mail. If your request is not approved and you still want the drug, you will have to pay the full price of the prescription.

All decisions are made based on FDA guidelines and current medical findings. Learn more about this at www.aetna.com/formulary.

Start your Aetna plan with peace of mind

New plans often come with new rules. We want to help make the change easier. Once your plan starts, you don’t have to worry about getting approval for most covered drugs for your first 90 days.

In your first 90 days:• If you need a covered drug that normally needs approval

first, you’ll be able to get that drug without the approval.

• For clinical reasons, some drugs will still need to be approved first, even in your first 90 days. This may be because of questions about dosing, quantity or other health concerns.

After 90 days:• You will need to choose a drug that is covered under

your plan, like a preferred alternative. Or request a medical exception.

• You will need approval for any new drugs that your doctor prescribes that would normally require precertification.

• If your doctor changes the dosage of your medication, you may then need to get it approved first. This will happen if the dosage is more than what the FDA recommends.

Over-the-counter drugs may be an option

Many health conditions can be treated safely with drugs you can get without a prescription. We call these drugs “over the counter” because you can buy them at your local stores. You don’t have to go to a pharmacy.

These drugs have been approved by the FDA as safe and effective, and they often have the same active ingredients as an original prescription version. Always talk to your doctor before taking over-the-counter drugs.

Your plan does not cover prescription drugs if a similar drug is available over the counter. This includes drugs like Claritin® and Prilosec® 20 mg. Please ask your doctor what will work best for you.

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Limitations and exclusions

Drugs that are not covered under the standard prescription drug benefit program include, but are not limited to:

• Drugs used for weight loss, including the treatment of obesity

• Some over-the-counter drugs

• Some nutritional supplements

• Smoking cessation aids or drugs

• Some growth hormones

• Prophylactic drugs for travel

• Test agents and devices, other than diabetic test agents

• Performance, athletic performance, or lifestyle enhancement drugs and supplies

• Cosmetics or any drugs used for cosmetic purposes or to promote hair growth, including health and beauty aids

• Replacement for lost or stolen prescriptions

For a complete list of what is not covered by your prescription drug plan, refer to your plan documents after enrollment.

Find out more

Once you are enrolled, log in to your secure Aetna Navigator member website at www.aetna.com.

You’ll find benefits and claims information, your Pharmacy Plan Drug list, cost estimates and more.

You can also refer to your Summary of Benefits or call us at the toll-free number on your Aetna member ID card.

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Limitations and exclusions

Medical

The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased.

Aetna HMO and Savings Plus HMOServices and supplies that are generally not covered include, but are not limited to:

• All medical and hospital services not specifically covered in, or that are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates

• Cosmetic surgery

• Custodial care

• Dental care and dental X-rays

• Donor egg retrieval

• Experimental and investigational procedures (except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial)

• Immunizations for travel or work

• Implantable drugs and certain injectable drugs

• Nonmedically necessary services or supplies

• Orthotics

• Over-the-counter medications and supplies

• Radial keratotomy or related procedures

• Reversal of sterilization

• Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling

• Special duty nursing

• Therapy or rehabilitation other than those listed as covered in the plan documents

Aetna Open Access Managed Choice (OAMC) Savings Plus OAMC plansServices and supplies that are generally not covered include, but are not limited to:

• All medical or hospital services not specifically covered in, or that are limited or excluded in the plan documents

• Charges related to any eye surgery mainly to correct refractive errors

• Cosmetic surgery, including breast reduction

• Custodial care

• Dental care and X-rays

• Donor egg retrieval

• Experimental and investigational procedures

• Immunizations for travel or work

• Nonmedically necessary services or supplies

• Orthotics

• Over-the-counter medications and supplies

• Reversal of sterilization

• Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling

• Special duty nursing

20

* These do not apply if the loss is caused by an infection that results directly from the injury or surgery needed because of the injury. The injury must not be one that is excluded by the terms of the contract.

Dental, AD&D Ultra and disability

Dental, AD&D Ultra and disability plans include limitations, exclusions and charges or services that these plans do not cover. For a complete list of all limitations and exclusions or charges and services that are not covered, please refer to your Aetna group plan documents. Limitations, exclusions and charges or services may vary by state or group size.

Dental

Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentist. The plan covers only those services and supplies that are medically necessary. Charges for the following services or supplies are limited or may be excluded:

• Dental services or supplies that are primarily used to alter, improve or enhance appearance

• Experimental services, supplies or procedures

• Treatment of any jaw joint disorder, such as temporomandibular joint disorder

• Replacement of lost, missing or stolen appliances and certain damaged appliances

• Those services that Aetna defines as not necessary for the diagnosis, care or treatment of a condition

• Specific service limitations:

- DMO plans: Oral exams (four per year)

- PPO plans: Oral exams (two routine and two problem-focused per year)

- All plans:

- Bitewing X-rays (one set per year)

- Complete series X-rays (one set every three years)

- Cleanings (two per year)

- Fluoride (one per year; children under 16)

- Sealants (one treatment per tooth, every three years on permanent molars; children under 16)

- Scaling and root planing (four quadrants every two years)

- Osseous surgery (one per quadrant every three years)

• All other limitations and exclusions in your plan documents

AD&D Ultra

Not all events that may be ruled accidental are covered by this plan. No benefits are payable for a loss caused or contributed to by:

• Air or space travel, unless a person is a passenger, with no duties at all, on an aircraft being used only to carry passengers (with or without cargo)

• Bodily or mental infirmity

• Commission of or attempt to commit a criminal act

• Illness, ptomaine or bacterial infection*

• Inhalation of poisonous gases

• Intended or accidental contact with nuclear or atomic energy by explosion and/or release

• Ligature strangulation resulting from auto-erotic asphyxiation

• Intentionally self-inflicted injury

• Medical or surgical treatment*

• Third-degree burns resulting from sunburn

• Use of alcohol

• Use of drugs, except as prescribed by a physician

• Use of intoxicants

• Use of alcohol or intoxicants or drugs while operating any form of a motor vehicle whether or not registered for land, air or water use. A motor vehicle accident will be deemed to be caused by the use of alcohol, intoxicants or drugs if it is determined that at the time of the accident you or your covered dependent was:

- Operating the motor vehicle while under the influence of alcohol at a level that meets or exceeds the level at which intoxication would be presumed under the laws of the state where the accident occurred. If the accident occurs outside of the United States, intoxication will be presumed if the person’s blood alcohol level meets or exceeds .08 grams per deciliter; or

- Operating the motor vehicle while under the influence of an intoxicant or illegal drug; or

- Operating the motor vehicle while under the influence of a prescription drug in excess of the amount prescribed by the physician; or

- Operating the motor vehicle while under the influence of an over-the-counter medication taken in an amount above the dosage instructions

• Suicide or attempted suicide (while sane or insane)

• War or any act of war (declared or not declared)

21

Disability

Disability coverage also does not cover any disability that:

• Is due to an occupational illness or occupational injury except in the case of sole proprietors or partners who cannot be covered by workers’ compensation

• Is due to insurrection, rebellion or taking part in a riot or civil commotion

• Is due to intentionally self-inflicted injury (while sane or insane)

• Is due to war or any act of war (declared or not declared)

• Results from your commission of, or attempt to commit a criminal act

• Results from a motor vehicle accident caused by operating the vehicle while the member is under the influence of alcohol. A motor vehicle accident will be deemed to be caused by the use of alcohol if it is determined that at the time of the accident the member was operating the motor vehicle while under the influence of alcohol at a level that meets or exceeds the level at which intoxication would be presumed under the laws of the state where the accident occurred. If the accident occurs outside of the United States, intoxication will be presumed if the person’s blood alcohol level meets or exceeds .08 grams per deciliter

Disability coverage does not cover any disability on any day that the member is confined in a penal or correctional institution for conviction of a criminal act or other public offense. The member will not be considered to be disabled, and no benefits will be payable.

No benefit is payable for any disability that occurs during the first 12 months of coverage and is due to a pre-existing condition for which the member was diagnosed, treated or received services, treatment, drugs or medicines three months prior to the coverage effective date.

Employee and dependent life insurance

The plan may not pay a benefit for deaths caused by suicide, while sane or insane, or from an intentionally self-inflicted injury, within two years from the effective date of the person’s coverage. If death occurs after two years of the effective date but within two years of the date that any increase in coverage becomes effective, no death benefit will be payable for any such increased amount.

Vision

Benefits are not provided for services or materials arising from: Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; medical and/or surgical treatment of the eye, eyes or supporting structures; any eye or vision examination, or any corrective eyewear required by a policyholder as a condition of employment; safety eyewear; services provided as a result of any workers’ compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; Plano (nonprescription) lenses and/or contact lenses; nonprescription sunglasses; two pair of glasses in lieu of bifocals; services or materials provided by any other group benefit plan providing vision care; certain brand-name vision materials in which the manufacturer imposes a no-discount policy; or services rendered after the date an insured person ceases to be covered under the policy, except when vision materials ordered before coverage ended are delivered, and the services rendered to the insured person are within 31 days from the date of such order. Lost or broken lenses, frames, glasses or contact lenses will not be replaced except in the next benefit frequency when vision materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans.

22

Find a doctor or specialist in the Aetna network

Start your search at www.aetna.com (or, if you are already a member, log in to Aetna Navigator). Click on Find a Doctor. Use the simple online instructions to perform a general search. Also, you may search for a particular physician by name, specialty or other options.

Savings PlusLook for the symbol.

23

How to find your Illinois plan

When performing a search in DocFind, you will be asked to select a plan name. Some of the names of our plans appear by their network names. Here is a quick reference to identify your plan:

Medical plan name as it appears in DocFind Common plan names

Savings Plus of Chicago, IL Savings Plus Open Access® Managed Choice® (OAMC)

Managed Choice POS (Open Access) Aetna Open Access® Managed Choice® (OAMC)

Savings Plus of Chicago, IL (HMO) HMO Aetna Savings Plus Plan

HMO HMO

Open Choice® PPO PPO

24

How to complete the enrollment form application (for groups with 2 to 50 employees)

Please be sure to complete your enrollment form thoroughly.

The sections noted below are frequently overlooked.

1. Indicate your date of hire.

2. Select the medical plan(s) offered by your employer.

3. Insert your Social Security number here.

4. Sign here if you are waiving coverage for yourself or any dependents.

5. Sign and date here to complete the form.

NOTE: Before submitting this completed form to your employer, you may wish to protect the confidentiality of your

health information by taping or stapling the form so that the health information page is not visible.

Illinois Group Business (2 - 50 Eligible Employees)

Employee Enrollment/Change Form

INSTRUCTIONS: You, the employee, must complete this enrollment form in full or it will be returned

to you resulting in a delay in processing. You are solely responsible for its accuracy and

completeness. If waiving coverage, please complete Sections B and F.

Group Number

Member Aetna ID Number (if available)

Company Name

Effective Date

New Hire

Rehire/Reinstatement

New Group Enrollment

Late Enrollment

Other

Change of Coverage

Add Spouse/Civil Union

Partner/Domestic Partner

Add Dependent Child

Name Change

Other

Employee

Termination

Remove Spouse/Civil

Union Partner/

Domestic Partner

Remove Dependent

Child

Cancel Coverage

COBRA State Continuation for:

Employee Dependent

Length of Continuation:

18 36 Other

Original Qualifying Event Date

Qualifying Event

Date of Hire

A. Coverage Selection – Please print clearly, using black ink. (Shaded sections for Employer/Aetna Use Only)

Control/Group No. Suffix Account Plan No. Class Code

1. Medical - Check applicable boxes. Employee Spouse/Civil Union Partner/Domestic Partner Child(ren)

HMO - Plan Option:

Managed Choice® (Open Access) - Plan Option:

Open Choice® PPO - Plan Option:

Savings Plus - Plan Option:

Idemnity - Plan Option:

Other:

Control/Group No. Suffix Account Plan No. Class Code

2. Dental - Check applicable boxes. Employee Spouse/Civil Union Partner/Domestic Partner Child(ren)

To enroll, enter plan number and name elected below.

Standard Plans: Plan Number Plan Name: For FOC, choose: DMO®

or PPO

Voluntary Plans: Plan Number Plan Name: For FOC, choose: DMO®

or PPO

Before today, were you covered under this employer’s dental plan? Yes No

Control/Group No. Suffix Account Plan No.

3. Life and Disability - Check applicable boxes.

Basic Life/AD&D Ultra®

Optional Dependent Life Short Term Disability Life & Disability Packaged Plan

Full Beneficiary Name (First, Middle, Last)

Beneficiary Social Security Number

Birthdate (MM/DD/YYYY)

/ /

Beneficiary Address (Number, Street, Apt. No., City, State, ZIP Code)

Telephone Number

( ) -

Relationship to Employee

B. Employee Information – Must be completed by the employee.

Social Security Number

Last Name, First Name, M.I.

Job Title

Home Telephone

Home Address

Apt. No.

City, State

ZIP Code

Work Address

City, State

ZIP Code

Work Telephone

Salary

$

Hourly

Monthly

Weekly

Primary Language

Spoken (Optional)

Number of

Hours Worked

Per Week

Check One:

Full-Time 1099 Seasonal

Part-Time Retired Temporary

Union COBRA

Number of Dependents

Including Spouse/Civil

Union Partner/Domestic

Partner

GR-68900-7 (6-13) 1 IL R-POD

D. Dependent Information

List any dependent in Section C living at another address.

Name Address

For Life Coverage: If age 19 and over and a full-time student, provide information below.

Child Name School Name Expected Graduation Date Number of Credit Hours

E. Coordination of Benefits

Will you have other health insurance at the same time as this coverage? Yes No

Name of Person Carrier Name Name of Person Carrier Name

F. Declination/Waiver of Coverage – Check all that apply

I understand I am eligible to apply for this coverage through my employer; however, I am waiving coverage as noted below.

Employee:

Medical Dental Life Disability

Reason for declining coverage

Spousal group coverage

Parental coverage

Medicare

Medicaid

Retiree coverage

Another group plan provided

by my employer

COBRA coverage

Insurance through another job

TRICARE or CHAMPVA

Individual coverage – On or Off Exchange

Do not want

Other

Spouse/Civil Union Partner/Domestic Partner:

Medical Dental Life

Child(ren):

Medical Dental Life

I certify I have been given the right to apply for this coverage; however, I am waiving coverage as noted above. By declining this group coverage I

acknowledge that myself and/or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage.

Please sign here ONLY if you are declining coverage for yourself and/or dependent(s).

X Employee Signature

Date (Month/Day/Year)

G. Case Management (OPTIONAL – This information will be used to help coordinate your care. It will not impact your premium rate or

eligibility for coverage.)

ALS (Amyotrophic lateral sclerosis) - Lou

Gehrig's disease

Auto Immune Disorders (e.g., scleroderma,

Systemic Lupus)

Traumatic Brain Injury

Cerebral Palsy using wheelchair

Chronic Pain

Clotting Disorder

Congestive Heart Failure

COPD using oxygen

Cor Pulmonale

Defibrillator /AICD/ Implantable Cardioverter

Dialysis

End of Life/Hospice

Hemodialysis

Morbid Obesity (BMI > 42)

Multiple Sclerosis

Muscular Dystrophy

Myasthenia Gravis

Paralysis

Paraplegic

Prosthesis present

Pregnant - high risk or multiple births

Quadriplegic

Surgery scheduled or pending

Other

Name of Individual Condition(s)

GR-68900-7 (6-13) 3 IL

Conditions of Enrollment

On behalf of myself and the dependents listed on Page 2:

1. I acknowledge that by enrolling in the following plans, coverage is provided by the following entities (collectively referred to as “Aetna”):

● Aetna HMO: Aetna Health Inc.

● Aetna Managed Choice®

Open Access and Open Choice® PPO: Aetna Life Insurance Company

● Life, Accidental Death & Personal Loss, disability, dental and all other coverages: Aetna Life Insurance Company.

2. I understand and agree that my employer’s application will determine coverage and that there is no coverage unless and until both this

Enrollment/Change Form and the employer application have been accepted by Aetna. Even if this Enrollment/Change Form is accepted, any

intentional and material misstatements or omissions that amount to fraud may result in future claims being denied and my coverage under the

policy being rescinded or reevaluated, as of the effective date, for eligibility and rating purposed except as otherwise provided by law.

For life and disability coverages: I understand that the effective date of insurance for myself or for any of my dependents is subject to my

being actively at work on that date and that the effective date of insurance for any of my dependents is also subject to the dependent health

condition requirements of the benefit plan. Further, I understand that any insurance subject to evidence of good health or medical information will

not become effective until Aetna gives its written consent. For Dependent Life, dependents are eligible from 14 days of age up to their 19th

birthday or up to their 23rd

birthday, if a full-time student.

3. I understand and agree that this Enrollment/Change Form may be transmitted to Aetna or its agent by my employer or its agent. I authorize any

physician, other healthcare professional, hospital or any other healthcare organization (“Providers”), including pharmacies or pharmacy database

benefit managers to give to Aetna or its agent information concerning the medical history, services or treatment provided to anyone listed on this

enrollment form, including those involving mental health, substance abuse and HIV/AIDS. I further authorize Aetna to use such information and

to disclose such information to affiliates, Providers, payors, other insurers, third party administrators, vendors, consultants and governmental

authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related

activities. I have discussed the terms of this authorization with my spouse/civil union partner/domestic partner and competent adult dependents,

and I have obtained their consent to those terms. Authorizations signed for the purpose of collecting information in connection with this

application for an insurance policy, a policy reinstatement or a request for a change in policy benefits shall remain valid for thirty (30) months from

the date it is signed. Authorizations signed for the purpose of collecting information in connection with a claim for benefits shall remain valid for

the term of this coverage or for so long as allowed by law. I understand that I am entitled to receive a copy of this authorization upon request and

that a photocopy is as valid as the original.

4. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits

comparison, summary or other description of the plan.

5. I understand and agree that, with the exception of Aetna Rx Home Delivery®, all participating providers and vendors are independent contractors

and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular

provider cannot be guaranteed and provider network composition is subject to change. Notice of the change shall be provided in accordance with

applicable state law.

6. I understand and agree that, with certain exceptions described in the plan documents, HMO and DMO® plans only provide coverage for referred

benefits, and that, in order to be covered, services must be performed either by a participating primary care physician, primary care dentist, or by

the participating specialist, hospital, pharmacy, dentist, or other provider as authorized by a referral from a participating primary care physician.

Misrepresentation

7. Any person who knowingly and with intent to defraud any insurance company or other person files an enrollment form for insurance or statement

of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto

commits a fraudulent insurance act.

I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions of Enrollment and Misrepresentation

on this Illinois Group Business Employee Enrollment/Change Form. I understand that, in the event I fail to sign this form within 31 days of my eligibility

date or for any reason Aetna does not receive notice of the above transaction request within a reasonable time following the event, my and my

dependents’ eligibility may be affected. I am employed by the employer shown on Page 1, and I am working full time at least 25 hours per week for this

employer at the regular place of business.

Employee Signature

X

Employee E-mail Address (optional)

Date (Month/Day/Year)

GR-68900-7 (6-13) 4 IL

2

3

1

4

5

25

How to complete the enrollment form application (for groups with 51 to 100 employees)

Please be sure to complete your enrollment form thoroughly.

The sections noted below are frequently overlooked.

1. Indicate your date of hire.

2. Select the medical plan(s) offered by your employer.

3. Insert your Social Security number here.

4. Sign here if you are waiving coverage for yourself or any dependents.

5. Sign and date here to complete the form.

NOTE: Before submitting this completed form to your employer, you may wish to protect the confidentiality of your

health information by taping or stapling the form so that the health information pages are not visible.

Illinois Business (51 - 100 Eligible Employees)

Employee Enrollment/Change Form

INSTRUCTIONS: You, the employee, must complete this enrollment form in full or it will be returned

to you resulting in a delay in processing. You are solely responsible for its accuracy and

completeness. If waiving coverage, please complete Sections B and G.

Group Number

Member Aetna ID Number (if available)

Company Name

Effective Date

New Hire

Rehire/Reinstatement

New Group Enrollment

Late Enrollment

Other

Change of Coverage

Add Spouse/Civil Union

Partner/Domestic Partner

Add Dependent Child

Name Change

Other

Employee

Termination

Remove Spouse/Civil

Union Partner/

Domestic Partner

Remove Dependent

Child

Cancel Coverage

COBRA for:

Employee Dependent

Length of Continuation:

18 36 Other

Original Qualifying Event Date

Qualifying Event

Date of Hire

A. Coverage Selection – Please print clearly, using black ink. (Shaded sections for Employer/Aetna Use Only)

Control/Group No. Suffix Account Plan No. Class Code

1. Medical - Check applicable boxes. Employee Spouse/Civil Union Partner/Domestic Partner Child(ren)

HMO - Plan option:

Managed Choice® (Open Access) - Plan option:

Open Choice® PPO - Plan option:

Savings Plus - Plan option:

Idemnity - Plan option:

Other:

Control/Group No. Suffix Account Plan No. Class Code

2. Dental - Check applicable boxes. Employee Spouse/Civil Union Partner/Domestic Partner Child(ren)

To enroll, enter plan number and name elected below.

Standard Plans: Plan Number Plan Name: For FOC, choose: DMO®

or PPO

Voluntary Plans: Plan Number Plan Name: For FOC, choose: DMO®

or PPO

Before today, were you covered under this employer’s dental plan? Yes No

Control/Group No. Suffix Account Plan No.

3. Life and Disability - Check if applicable.

Basic Life/AD&D Ultra®

Optional Dependent Life Short Term Disability Life & Disability Packaged Plan

Full Beneficiary Name (First, Middle, Last)

Beneficiary Social Security Number

Birthdate (MM/DD/YYYY)

/ /

Beneficiary Address (Number, Street, Apt. No., City, State, ZIP Code)

Telephone Number

( ) -

Relationship to Employee

B. Employee Information – Must be completed by the employee.

Social Security Number

Last Name, First Name, M.I.

Job Title

Home Telephone

Home Address

Apt. No.

City, State

ZIP Code

Work Address

City, State

ZIP Code

Work Telephone

Salary

$

Hourly

Monthly

Weekly

Primary Language

Spoken (Optional)

Number of

Hours Worked

Per Week

Check One:

Full-Time 1099 Seasonal

Part-Time Retired Temporary

Union COBRA

Number of Dependents

Including Spouse/Civil

Union Partner/Domestic

Partner

GR-68901-7 (6-13) 1 IL R-POD

E. Medicare Information

Name of Person

Medicare

Part A

Medicare

Part B

Medicare

Part D Over Age 65 Disability

End-Stage Renal

Disease Effective

Date

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

F. Coordination of Benefits

Will you have other health insurance at the same time as this coverage? Yes No

Name of Person Carrier Name Name of Person Carrier Name

G. Declination/Waiver of Coverage – Check all that apply

I understand I am eligible to apply for this coverage through my employer; however, I am waiving coverage as noted below.

Employee:

Medical Dental Life Disability

Reason for declining coverage

Spousal group coverage

Parental coverage

Medicare

Medicaid

Retiree coverage

Another group plan provided

by my employer

COBRA coverage

Insurance through another job

TRICARE or CHAMPVA

Individual coverage – On or Off Exchange

Do not want

Other

Spouse/Civil Union Partner/Domestic Partner:

Medical Dental Life

Child(ren):

Medical Dental Life

I certify I have been given the right to apply for this coverage; however, I am waiving coverage as noted above. By declining this group coverage I

acknowledge that myself and/or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage.

Please sign here ONLY if you are declining coverage for yourself and/or dependent(s).

X Employee Signature

Date (Month/Day/Year)

H. Health Questionnaire must be completed when the employer group is:

• A virgin group;

• A newly formed business;

• Requesting Life coverage above the Guaranteed Issue amount.

Health History for Individuals and your Dependents. The following information is confidential and will not be seen by or given to your

employer. • ALL of the questions must be answered by you and your dependents or the application will be returned.

• Incomplete enrollment forms may delay the effective date of your coverage.

List all individuals enrolling for coverage.

Name Sex Age Height Weight

Cigarette

Smoker

Currently Taking

Prescription

Medication(s)

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

I. Answer all questions. 1. Within the last five years has anyone applying for coverage consulted, received treatment, by a doctor, psychiatrist,

psychologist, or other practitioner or been diagnosed with any of the following conditions or disorders? (Check all that apply.) Yes No

a. AIDS/ARC/HIV

b. Diabetes

c. Infertility

d. Endocrine

Metabolic

e. Pancreas

f. Liver/Hepatitis

g. Immune System

h. Blood Disorder

i. Hemophilia

j. Epilepsy/Seizure

k. Heart Disorder/Disease

l. Paralysis/Paresis

m. Tumor/Cyst/Growth

n. Systemic or Discoid Lupus

o. Lung or Respiratory

p. Alcohol or Drug Use

q. Kidney/Bladder/Urinary

r. Circulatory/Vascular

s. Digestive/Stomach/Intestinal

t. Central Nervous System

u. Connective Tissue Disorder

v. Pituitary/Adrenal/

Growth Disorder

w. Birth Defects/Congenital Abnormalities

x. Arthritis/Bone/Joint/Muscle/Prosthetic Device

y. Mental/Nervous/Emotional/Eating Disorder

z. Stroke/Brain/Neurological

aa. Transplant: Recommended Pending Complete

bb. Advised to have tests, surgery, hospitalization or

is treatment needed, or course of treatment not yet

determined

cc. Cancer: Type: Stage

Surgery Chemo Radiation

dd. Using: Crutches Walker Wheelchair

ee. Other

continued on next page

GR-68901-7 (6-13) 3 IL

Conditions of Enrollment (continued)

4. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits

comparison, summary or other description of the plan.

5. I understand and agree that, with the exception of Aetna Rx Home Delivery®, all participating providers and vendors are independent contractors

and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular

provider cannot be guaranteed and provider network composition is subject to change. Notice of the change shall be provided in accordance with

applicable state law.

6. I understand and agree that, with certain exceptions described in the plan documents, HMO and DMO® plans only provide coverage for referred

benefits, and that, in order to be covered, services must be performed either by a participating primary care physician, primary care dentist, or by

the participating specialist, hospital, pharmacy, dentist, or other provider as authorized by a referral from a participating primary care physician.

Misrepresentation

7. Any person who knowingly and with intent to defraud any insurance company or other person files an enrollment form for insurance or statement

of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto

commits a fraudulent insurance act.

I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions of Enrollment and Misrepresentation

on this Illinois Business Employee Enrollment/Change Form. I understand that, in the event I fail to sign this form within 31 days of my eligibility date or

for any reason Aetna does not receive notice of the above transaction request within a reasonable time following the event, my and my dependents’

eligibility may be affected. I am employed by the employer shown on Page 1, and I am working full time at least 25 hours per week for this employer at

the regular place of business.

Employee Signature

X

Employee E-mail Address (optional)

Date (Month/Day/Year)

GR-68901-7 (6-13) 5 IL

2

3

1

4

5

26

www.aetna.com PAYER# 60054 0000

Legal Entity Prints HereAT

0110

P.O. BOX 981106EL PASO TX 79998-1106

MEMBER SERVICESPROVIDERS CALLRX MEMBER SERVICES

1-888-888-88881-888-632-38621-888-792-3862

The primary care physician copay is for the doctor you choose. The specialist copy is for all other doctors in the network. Referrals are not required. However, some services may also require precertification. Without pre-approval, you may pay more or even full price. For mental health or substance abuse pre-approval or coverage questions, call 1-800-242-4047, See your plan documents for information on your plan requirements. In an emergency call 911 or go to the nearest emergency room. Note: This card does not guarantee coverage.

RX BIN# 610502

PLAN SPONSOR NAME HERE LINE 1PLAN SPONSOR NAME HERE LINE 2

NAP

NAME

Managed ChoiceOpen Access

ID W1234 56789

GRP# 012345-010-00013Issuer (80840) 9140860054

01 JOHN SAMPLE02 JANE SAMPLE03 JACKSON SAMPLE04 JESSE SAMPLE05 JEFFERY SAMPLE

PCP: ABC Family PracticePCP: ABC Family PracticePCP: ABC Family PracticePCP: ABC Family PracticePCP: ABC Family PracticeDEDUCTIBLE MAY APPLYPCP $ 25.00SPC $ 40.00

NAP Vendor Logoor Network Logo

Your member ID card

After you enroll, you will receive ID cards that look like this. If you need care before your ID card arrives in the mail, you may log in to Aetna Navigator and print a temporary ID card. Make sure to present your Aetna ID card when receiving care from participating providers or when accessing emergency care. Your ID card identifies you as an Aetna member.

Plan in which you are enrolled.

Call this number to speak with a Member Services representative.

27

Contact informationMember services

Medical

For Aetna HMO plans 1-866-529-2517

Aetna P. O. Box 981106 El Paso, Texas 79998-1006

For Aetna PPO, consumer-directed or indemnity plans 1-888-802-3862 Prompt 1

Aetna P.O. Box 981204 El Paso, TX 79998-1204

Dental

1-877-238-6200 Prompt 1 (Dental plan member) Prompt 2 (Dental care provider)

Aetna P.O. Box 14066 Lexington, KY 40512-4066

Life

1-800-523-5065

Claims address: Aetna Life Insurance P.O. Box 14548 Lexington, KY 40512-4548

Claims

1-866-474-4040 (fax)

Disability

1-888-584-2981

Aetna Life Insurance Company P.O. Box 14552 Lexington, KY 40512-4552

Pharmacy

1-800-AETNA RX or 1-800-238-6279

Prompt 2 (Member or calling on behalf of a member)

Aetna Pharmacy Management P.O. Box 14024 Lexington, KY 40512 1-860-262-9427 (fax)

Mail-Order Drugs

1-866-612-3862

Ordering address: Aetna Rx Home Delivery P.O. Box 417019 Kansas City, MO 64179-9892

Other Programs

Aetna Vision Discount Program 1-800-793-8616 Call for closest eye care provider

Informed Health® Line 1-800-556-1555 24-hour nurse help line

Aetna Behavioral Health 1-800-424-5702

For other discount programs, or to access the Docfind® online provider directory, log in at www.aetna.com.

Visit your secure member website onlineYour secure Aetna Navigator member website is available 24 hours a day, 7 days a week. Use it to perform common transactions involving your Aetna medical, dental, prescription drug or flexible spending account (FSA) plans. You can send a secure e-mail to Aetna Member Services, access claims, see who’s covered, and view general health information and decision-support tools. Log in to the Aetna Navigator website at www.aetna.com.

If you need this material translated into another language, please call Member Services at 1-888-98-AETNA (1-888-982-3862).Si usted necesita este documento en otro idioma, por favor llame a Servicios al Miembro al 1-888-98-AETNA (1-888-982-3862).This material is for information only and is neither an offer or invitation to contract. The models depicted are not Aetna members. An application must be completed to obtain coverage. Rates and benefits vary by location. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Health and life insurance plans contain exclusions and limitations. Discount offers provide access to discounted services and are not part of an insured plan or policy. Discount offers are rate-access offers and may be in addition to any plan benefits. Check any insurance benefits you have before using these discount offers, as those benefits may result in lower costs to you than using these discounts. Discount offers are not guaranteed and may be discontinued at any time. Aetna makes no payment to the discount vendor. The member is responsible for the full cost of the discounted services. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Aetna does not endorse any vendor, product or service associated with these discount offers. Vendors are independent of Aetna, not agents or employees thereof. Programs, products and services may not be available at all times. Certain offers may not be available in some states. Products may be subject to a warranty from the manufacturer. Aetna makes no representations or warranties, and disclaims all product warranties. The discount offers have no liability for providing or guaranteeing service and assumes no liability for the quality of service rendered. Aetna may receive a percentage of the fee paid to a discount vendor.Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy providing prescription services by mail. This pharmacy is a for-profit entity. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. Vision insurance plans are underwritten by Aetna Life Insurance Company (Aetna). Certain claims administration services are provided by First American Administrators, Inc. and certain network administration services are provided through EyeMed Vision Care (“EyeMed”), LLC. Providers participating in the Aetna Vision network are contracted through EyeMed Vision Care, LLC. EyeMed and Aetna are independent contractors and not employees or agents of each other. Participating vision providers are credentialed by and subject to the credentialing requirements of EyeMed. Aetna does not provide medical/vision care or treatment and is not responsible for outcomes. Aetna does not guarantee access to vision care services or access to specific vision care providers and provider network composition is subject to change without notice. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

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©2015 Aetna Inc. 14.03.295.1-IL A (6/15)

Review the material in this brochure and speak with your employer or human resources representative about the choices available to you.

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