Your Aetna plan features, and how to enroll · Choice – Find a range of resources to help balance...

Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions

XX.XX.XXX.X (X/12)

www.aetna.com

Nevada Small Group Enrollment Guide

Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions

14.05.902.1-NV (9/14)

Your Aetna plan features, and how to enroll

www.aetna.com

Plans effective January 1, 2015

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

Learn about:Member tools, how to enroll and value-added programs.

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Welcome to your healthy!

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 4

Aetna Navigator health programs 4

Personal Health Record 5

Health care transparency tools 6

Employee Assistance Program (EAP) 6

RelayHealth® website 7

Informed Health® Line 9

Walk-in clinics 9

Urgent care 9

Member discounts 10

Special programs for the needs of women 13

Women’s preventive health benefits 14

Disease management program 17

Pediatric dental/vision 18

Medical products 19

Get to know your Aetna prescription drug plan 21

Dental products 24

Life insurance programs that do more 29

Find quality doctors and specialists in the Aetna network 30

How to complete the enrollment form 32

Your member ID card 33

Contact information 34

4*If included in your plan.

Aetna Navigator®

Your secure member website

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

Your secure Aetna Navigator website is a single source for online health and benefits information. It’s convenient, and easy to use. Once your health plan is active, you can:

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

• Get a member ID card

• 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 benefits summary – allows you to find 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 formulary

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

• Aetna SmartSourceSM search 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® interactive consumer website for credible health, dental and wellness information provided by Harvard Medical School

• Healthwise® Knowledgebase, a user-friendly online information tool that lets you research your own issues and preferences for health information. It also has interactive and streaming videos about topics such as asthma and heart health

Health programs

Earn $50 in just a few simple steps

You can earn a $50 credit toward your out-of-pocket expenses when you:

• Complete or update your Simple Steps To A Healthier Life®, health assessment, and

• Complete one online wellness program

If your spouse is covered under the plan, he or she is also eligible for the same incentive credit. So a family could save $100 in out-of-pocket expenses each year. Incentive rewards will be credited toward the deductible and maximum out-of-pocket limit. This program is included at no additional cost on all plans except HMO and HSA-compatible plans.

5* The Aetna Personal Health Record should not be used as the sole source of information about the member’s health history.

Personal Health RecordPut your health information in one place

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 appears 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

The 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.

Portability ensures your personal health records go where you go

Our relationship with Microsoft allows you to 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 your emergency contact’s name and phone number, your insurance details, any medications you are taking, allergies if you have any and if you have a living will or have designated your organs for donation. All this detail is in a single 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 today!

It’s easy to get started.

Visit your Personal Health Record after you enroll 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.

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Health care transparency tools

Since 2005, we have empowered members with our suite of tools that inform you about doctors, hospitals and other medical facilities. You can make more informed health care decisions by using our online transparency tools before visiting a doctor or hospital.*

With our transparency tools, you can:

• 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 since the information is available 24/7 through your secure Aetna Navigator website secure member website, and DocFind

This combination of physician-specific rates, clinical quality and efficiency, and facility-specific medical procedure costs is a first from a national health carrier and demonstrates our commitment to you.

To access our health care transparency tools after your plan’s effective date, log in to Aetna Navigator. Click on Estimate Cost of Care from the Care & Treatment tab. There, you can use 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

Employee Assistance Program (EAP)*** (51 – 100 employees only)

Our Employee Assistance Program is a confidential program that gives you 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 – Find a range of resources to help balance your personal and professional lives.

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

Professional assistance – Trained specialists provide confidential phone support, assessing needs and recommending an appropriate course of action. You get three phone consultations (per member) in a calendar year.

* 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.

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

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RelayHealthSave time with online doctor visits

Visit your doctor with webVisit® online

Our latest innovative health care benefit in partnership with RelayHealth* lets you communicate effectively and securely online with your doctor to seek 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.

Simply register on the RelayHealth website at www.relayhealth.com/Patients/Registration.aspx to get started.

Once registered, log in at your convenience to take advantage of the many features 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.

A safe, easy way to visit your doctor

E-mail webVisit

• May not be secure or HIPAA (Health Insurance Portability and Accountability Act)-compliant.

• Free form – you may not know the medical questions to address so your doctor can diagnose your ailment.

• Non-chargeable – eligibility needs to be determined and you must submit a claim.

• HIPAA-compliant – secure and authenticated with user login.

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

• Reimbursable – checks eligibility in real time, collects copayment and submits claim automatically.

A few things to note before you get started:

• You must have an established relationship with a doctor before using webVisit.

• Your doctor must be a member of the Aetna network and be registered as a participating provider in the RelayHealth physician network — participating providers are identified on DocFind through the Aetna Navigator.

* This feature does not apply to any HMO plan. Physicians will be paid for services provided according to the terms of their contract. As always, a member’s financial responsibility depends on the terms of his or her plan, which may vary.

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Teledoc*when doctor’s office hours won’t work for you.

We are pleased to provide you with access to Teledoc, an added benefit that gives you 24/7 access to a national network of U.S. board-certified doctors.

You can talk to a doctor by phone or online video about non-emergency care. Teledoc physicians can diagnose, treat and write prescriptions, when necessary.

What is Teledoc for?

• Cold and flu symptoms

• Ear infections

• Bronchitis

• Allergies

• Urinary tract infection

• Pink eye

• And more

Find out more and set up your account at the Teledoc website at www.teledoc.com/aetna.

* Teladoc and Teladoc physicians are independent contractors and are neither agents nor employees of Aetna. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.

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Informed Health® 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 (available 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 tell you how to 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.

Walk-in clinics*Looking for a convenient way to get medical care? Consider a walk-in clinic. It’s a convenient alternative to the doctor’s office. Use them when you have a common ailment and need to see a doctor, but it’s after business hours.

And walk-in clinics are not just for when you are sick. You might be surprised by the full spectrum of services available at a walk-in clinic, many of which are staffed by physician assistants and nurse practitioners. They offer:

• No appointments needed. The name says it all — just walk right in.

• Convenient hours. Some clinics are open seven days a week, with extended evening and weekend hours, just like the ER.

• Lower prices. You’ll pay an average of $44 to $59 per clinic visit** compared to the $550 to $750 average ER price.***

• Quicker care. The average ER visit tops four hours,† while clinic visits are generally an hour or less.

• Skilled staff. Clinics are overseen by a doctor, with nurse practitioners or physician assistants onsite.

Urgent care

If you need care that’s more than minor, we also contract with urgent care centers to give you an affordable alternative to the ER, at an average cost break of up to seven times less than your typical ER cost. The sites are staffed with doctors to handle urgent medical matters. And just like retail clinics, evening and weekend hours are available, with no appointments needed.

If your medical need is more than urgent — for example, characterized by chest pain, trouble breathing, bad bleeding or other symptoms that are serious or put your life at risk — you should go straight to your local ER.

• No appointments needed. Just walk right in.

• Convenient hours. Some centers are open seven days a week, with extended evening, weekend and holiday hours, just like the ER.

• Lower prices. Lower copays and out-of-pocket costs,with prices averaging $110 to$150,** compared to ER costs of $550 to $750.**

• Less waiting. The average ER visit tops four hours,† while urgent care visits are generally an hour or less.

• Fully staffed by doctors. Clinics are overseen by doctors, with doctors providing the service.

• Connections with local ERs. If you need more extensive care, you’ll be referred to the closest ER.

Check your Summary of Benefits and Coverage to get more information about coverage and costs to visit a walk-in clinic or urgent care center.†† To find the closest walk-in clinic or urgent care center near you, simply log in to Aetna Navigator, select Find A Doctor, Pharmacy or Facility and follow the easy online instructions.

*Walk-in clinics do not apply to Aetna Whole Health/PrimeCare Physicians Network members.

**Average retail and ER pricing. Based on Aetna average claim costs. For illustrative purposes only.

*** Member responsibility may vary based on plan design; for some plan copays apply. Emergency room copays are typically higher than walk-in clinic copays.

† The Case for Urgent Care (complimentary white paper). Urgent Care Association of America. Available at www.ucaoa.org/docs/WhitePaperTheCaseforUrgentCare.pdf. Accessed July 1, 2013.

†† Nevada HMO members must contact their medical group or primary care physician for walk-in clinic and urgent care center use.

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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: Save on your purchase of books, greeting cards and kits.1 Order online or by phone.

• Mayo Clinic Bookstore: Save on books and DVDs purchased online.

• Pranamaya: Save 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

• 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

• 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: You’ll get 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: You can get a discount off 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

You can 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

You can save on Waterpik 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

- 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

Choose from these offers:

- FREE 30-day program3

- Percent off the Jenny All Access Program enrollment fee3

• Nutrisystem

- Save 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.

As a member, you can access details and information on how to get started through Aetna Navigator.

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Special programs for the needs of women

Ongoing health management

Work, 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.

Preventive programs for women

Our preventive programs include:

• 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 online

Go to 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

• A pregnancy guide

• Food pyramid recommendations

• Information on diet and nutrition

For OB/GYN care, no referrals needed

For an annual well-woman exam, unlimited visits for gynecological problems and routine maternity care, women may schedule an appointment with participating obstetrical, gynecological or women’s health care professionals.

Special maternity care

From 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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Covered preventive services for women

Screenings and counseling for:

• BRCA (counseling and genetic testing for women of high risk with no personal history of breast and/or ovarian cancer)

• Breast cancer chemoprevention (for women at higher risk)• Breast cancer (mammography every one to two years

for women over 40)• Cervical cancer (for sexually active women)• Chlamydia infection (for younger women and other women

at higher risk)• Gonorrhea (for all women at higher risk)• Interpersonal or domestic violence• Osteoporosis (for women over age 60 depending on

risk factors)

Medications and supplements:

• Folic acid supplements (for women of child-bearing ages)

Contraceptive products and services:

• Prescribed FDA-approved female over-the-counter or generic contraceptives* when filled at an in-network pharmacy

• Two visits a year for patient education and counseling on contraceptives is also covered under your Aetna medical plan

Covered preventive services for pregnant women

• Routine prenatal visits (you pay your normal cost share for delivery, postpartum care, ultrasounds or other maternity procedures, specialist visits and certain lab tests)

• Anemia screenings• Diabetes screenings• Bacteriuria urinary tract or other infection screenings• Rh incompatibility screening, with follow-up testing for

women at higher risk• Hepatitis B counseling (at the first prenatal visit)• Expanded counseling on tobacco use• Breastfeeding interventions to support and promote

breastfeeding after delivery, including up to six visits with a lactation consultant

Covered preventive supplies for pregnant women

• Certain standard electric breastfeeding pumps (non-hospital-grade) anytime during pregnancy or while you are breastfeeding once every three years

• Manual breast pump any time during pregnancy or after delivery for the duration of breastfeeding

• Breast pump supplies, if you get pregnant again before you are eligible for a new pump

For more information go to www.aetna.com and search for “breast pumps.” Or call Member Services for details on how to use this benefit.

* Brand-name contraceptive drugs, methods or devices only covered with no member cost sharing under certain limited circumstances when required by your doctor due to medical necessity. Certain religious employers and organizations may choose not to cover contraceptive services as part of the group health coverage.

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No-cost preventive care Coverage for the whole family

Your health benefits and insurance plan covers routine screenings and checkups with no cost share as part of preventive care. It also includes counseling you get to prevent illness, disease or other health problems.

Many of these services are covered as part of physical exams. These include regular checkups, and routine gynecological and well-child exams. You won’t have to pay out of pocket for these preventive visits, when provided in network.

But these services are generally not preventive if you get them as part of a visit to diagnose, monitor or treat an illness or injury. Then copays, coinsurance and deductibles may apply.

We follow the recommendations of national medical societies about how often children, men and women need these services. Be sure to talk with your doctor about which services are right for your age, gender and health status.

Covered preventive services for adults generally include:

Screenings for:

• Abdominal aortic aneurysm (one-time screening for men of specified ages who have ever smoked)

• Alcohol misuse

• Blood pressure

• Cholesterol (for adults of certain ages or at higher risk)

• Colorectal cancer (for adults over 50)

• Depression

• Type 2 diabetes (for adults with high blood pressure)

• HIV

• Obesity

• Tobacco use

• Syphilis (for all adults at higher risk)


• Aspirin for men and women age 45 and older with certain cardiovascular risk factors

• Vitamin D supplements for adults age 65 and older with certain conditions

Counseling for:

• Alcohol misuse

• Diet (for adults with high cholesterol and other known risk factors for cardiovascular and diet-related chronic disease)

• Obesity

• Sexually transmitted infection (STI) prevention (for adults at higher risk)

• Tobacco use (including programs to help you stop using tobacco)

Immunizations:

Doses, recommended ages, and recommended populations vary

• Diphtheria, pertussis, tetanus (DPT)

• Hepatitis A and B

• Herpes zoster

• Human papillomavirus (HPV)

• Influenza

• Measles, mumps, rubella (MMR)

• Meningococcal (meningitis)

• Pneumococcal (pneumonia)

• Varicella (chicken pox)

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Covered preventive services for children

Screenings and assessments for:

• Alcohol and drug use (for adolescents)• Autism (for children at 18 and 24 months)• Behavioral issues• Cervical dysplasia (for sexually active females)• Congenital hypothyroidism (for newborns)• Developmental screening (for children under age three, and

surveillance throughout childhood)• Hearing (for all newborns)• Height, weight and body mass index measurements• Lipid disorders (dyslipidemia screening for children at

higher risk)• Hematocrit or hemoglobin• Hemoglobinopathies or sickle cell (for newborns)• HIV (for adolescents at higher risk)• Lead (for children at risk of exposure)• Medical history• Obesity• Oral health (risk assessment for young children)• Phenylketonuria (PKU) (newborns)• Tuberculin testing (for children at higher risk of tuberculosis)• Vision


• Gonorrhea preventive medication for the eyes of all newborns

• Iron supplements (for children ages six to 12 months at risk for anemia)

• Oral fluoride for children six months to five years of age (prescription supplements for children without fluoride in their water source)

Counseling for:

• Obesity• Sexually transmitted infection (STI) prevention (for

adolescents at higher risk)

Immunizations:

From birth to age 18 — doses, recommended ages and recommended populations vary

• Diphtheria, pertussis, tetanus (DPT)• Haemophilus influenzae type b• Hepatitis A and B• Human papillomavirus• Inactivated poliovirus• Influenza• Measles, mumps, rubella (MMR)• Meningococcal (meningitis)• Pneumococcal (pneumonia)• Rotavirus• Varicella (chicken pox)

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Disease management program Personal attention for your health conditions and risks

Ready to be your healthiest you?

You can get solid support managing your condition with the disease management program. And it’s included with Aetna health benefits and insurance plans, so you can start living healthier as soon as your plan is effective.

You’ll learn how to:

• Manage your condition

• Lower your risks for new conditions

• Work better with your doctor

• Take your medicine safely

• Find helpful resources

Support for more than 35 conditions

This includes diabetes, heart disease, cancer, low back pain and digestive conditions. Your condition is likely covered, too.

A program that’s about you, not your condition

Your condition isn’t unique. But you sure are. So this program is designed to help you control your condition in ways that work for you. You can:

• Work with a nurse when it fits your schedule

• Take online disease management programs to boost your nurse coaching sessions

• Interact with the program online, by e-mail or by phone

Call our dedicated disease management line toll-free, 24/7.

Work one on one with a registered nurse

An Aetna nurse will act as your personal health coach. You choose why, when or how often to speak with him or her.

You can work with your coach:

• Before or after your doctor visits

• When you’re looking for healthier lifestyle choices

• To understand your doctor’s treatment plans

Only your doctor can decide on the best care for you. But your health coach is by your side with tips and ideas to help.

Manage your condition with online programs

You may have access to online disease management programs, too. They can supplement the progress you’re making with your nurse.

Program topics include:

• General condition management

• Low back pain

• Diabetes

• Pain management

• High cholesterol

• High blood pressure

Technology that works for your health and safety

You benefit from smart technology that keeps scanning your health plan records. So if you visit the doctor or pick up a prescription, the system “knows” you did it.

It also scans information you or your care team entered into your Personal Health Record. Then it compares that information with current care guidelines to help you be safer and healthier.

This technology can suggest:

• Stopping or adding a drug

• Considering a procedure or test not given

• Thinking about preventive care or wellness options

You may also get a call or letter, depending on the situation.

What’s the program like?

Let’s say you have diabetes. Here’s how a nurse would work with you to manage your condition today — and going forward.

He or she would:

• Teach you about diabetes, and answer your questions

• Send you information by mail or e-mail, or point you to online resources

• Go over your doctor’s treatment plan with you

• Explain possible side effects of your medicine

How to start the program

If you need help, there are a few ways we’ll be able to find you:

• Your doctor’s referral

• Your medical or prescription claims

• Our Patient Management staff

If you have a condition, or think you’re at risk:

• Put in a request through your Aetna Navigator member website at www.aetna.com

• Call us at 1-866-269-4500

18

Pediatric dental/visionfor children up to age 19 (for groups with 2 to 50 employees)

These plans do not cover all vision or dental expenses and have exclusions and limitations. Members should refer to their plan documents to determine which services are covered and to what extent.

Pediatric vision

PPO plans PPO HSA plans

HMO plans with deductible

HMO plans with no deductible Indemnity

Participating Nonparticipating Participating Nonparticipating Participating Participating No network

Vision exam (one exam per 12 months)

0%; deductible waived

50% after deductible




0% 20%; deductible waived

Frames, lenses or contacts (per 12 months)



0% after deductible



0% 0%; deductible waived

Pediatric dental

PPO plans PPO HSA plans PPO 100% plan

Participating Nonparticipating Participating Nonparticipating Participating Nonparticipating

Dental checkup (preventive/diagnostic)



0% after deductible




Dental basic30% after deductible




0% after deductible


Dental major50% after deductible




0% after deductible


Dental ortho (after 24 months of continuous coverage)





0% after deductible


HMO plans with deductible

HMO plans with no deductible Indemnity

Participating Participating No network

Dental checkup (preventive/diagnostic) 0%; deductible waived 0% 0%; deductible waived

Dental basic 30% after deductible 30% 30% after deductible

Dental major 50% after deductible 50% 50% after deductible

Dental ortho (after 24 months of continuous coverage)

50% after deductible 50% 50% after deductible

19* According to the Aetna Enterprise Provider Database as of October 25, 2014. Network subject to change.

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

Plan features PPO HDHPAVN/HMO

Coverage for preventive care • • •

No PCP requirement • •

No referrals • •

Out-of-network access • •

Walk-in clinics • •

No claim forms (in network) • • •

A fund established to pay for eligible out-of-pocket health care expenses

•

Tax preferred account •

Premium affordability scale ($ – $$$ from lowest to highest costs)

$$ $ $

The Aetna network has more than 5,771 health care providers and 42 hospitals in Nevada.* So whichever plan you choose, you will be able to find the provider to best suit your needs.

Plan levels

Each level is based on how much of the total health care cost the plan pays, versus what you pay out of pocket. The levels are called bronze, silver, gold and platinum.

Health plan levelsAverage amount the plan pays for covered services

Bronze 60%

Silver 70%

Gold 80%

Platinum 90%

Use DocFind to search for a provider or select a primary care physician (PCP).

www.aetna.com/docfind

Or you can call the Member Services number on your ID card to order a printed physician directory.

20

Health care terms to knowPremiums are the amount you pay for your insurance policy, often deducted from your paycheck.

Deductibles are paid out of pocket each year before your medical plan covers expenses. Each family member usually has a separate deductible to meet before the medical plan starts coverage.

Copayments (copay) are flat fees charged each time you visit the doctor or use certain medical services, regardless of the cost of the procedure. Doctor’s visits and pharmaceutical purchases are often subject to copays.

Coinsurance requires you to pay a percentage of the cost of the medical services.*

Out-of-pocket limits is the maximum amount you’ll have to spend before all of your medical bills are covered by the medical plan. Deductibles, copays, coinsurance and pharmacy costs accumulate toward your out-of-pocket limit.

Use DocFind to search for a provider or select a primary care physician (PCP).www.aetna.com/docfind

HMO Member Services 1-866-529-2517

PPO Member Services 1-888-802-3862

*Some plans may require a copay and/or coinsurance for some types of services.

21

Get to know your Aetna prescription drug plan

You are enrolled in a four-tier, Aetna Value Plus formulary plan

Here’s what that means to you:

Think of tier as a level. Four tier means you could pay four different amounts, depending on the drug you take.

A formulary is a list of generic and brand-name drugs that your health plan covers. Your Aetna Value Plus formulary plan covers many drugs — but it does not cover drugs on the Formulary Exclusions List. This is a list of drugs your plan does not cover because there are just-as-effective and less expensive alternatives available.

Your cost depends on your prescription

With this health benefits and health insurance plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percent of the prescription’s price. Or, you will pay the full cost of any drugs on the Formulary Exclusions List.

What you pay falls into one of these tiers or levels:

Tier One: Preferred Generics – You pay the lowest cost for drugs in this level.

Tier Two: Preferred Brands – You pay a slightly higher cost for drugs in this level.

Tier Three: Nonpreferred Generic and Brand Drugs – You pay the highest cost for drugs in this level.

Tier Four: Preferred and Nonpreferred Specialty Drugs – You pay a specific amount for specialty drugs in this level. Specialty drugs may be injected, infused or taken by mouth.

Formulary Exclusions List – You will pay the full cost of any drugs on this list.

To find your exact costs

Check your Summary of Benefits & Coverage document. This should be in your enrollment kit.

Your pharmacy benefits plan may include a program that encourages you to choose a generic drug over a brand-name drug, in order to help reduce what you pay. This means if you fill a brand-name drug when a generic is available, that in addition to your standard copay or coinsurance, you must also pay the difference in cost between the brand-name and generic drug.

For a summary of your pharmacy benefits plan, including out-of-pocket costs, visit www.aetna.com and log in to Aetna Navigator. Or call the toll-free number on your member ID card.

Save on your prescriptions

Here are some tips to pay less out of pocket for your prescription drugs:

• Ask your doctor to consider prescribing drugs that are on the Aetna Preferred Drug (formulary) List.

• Ask your doctor to consider prescribing generic drugs instead of brand-name drugs.

• Check to see if your plan includes our mail-order pharmacy service. Depending on your plan, mail order may save you money. See next page for more information.

• Remind your doctor to check your plan to make sure you get maximum coverage.

You may have to get plan authorization for certain drugs

This drug coverage review encourages appropriate and cost-effective use of prescription drugs by allowing coverage only when certain conditions are met.

Reasons for this approval (called precertification) include:

• Compliance with dosing guidelines

• Avoiding duplicate therapies

• Helping health care providers check that a drug is being used based on generally accepted medical criteria

The precertification program is based on current medical findings, FDA-approved manufacturer labeling information, and cost and manufacturer rebate arrangements.

Please keep the following in mind:

• Your doctor must contact us to request approval of coverage for these drugs.

• If we approve the request, we will notify your doctor. The drug will then be covered at the applicable out-of-pocket cost under your plan. You will also be notified of approvals where the state requires notification to members.

If the request is denied, you and your doctor will be notified. You can still purchase the drug, but for the full price.

You may have to try one drug before another will be covered

This drug coverage review promotes the appropriate use of equally effective but lower-cost drugs first. Prerequisite drugs are FDA-approved and treat the same condition as the corresponding step-therapy drugs.

22

Mail order brings drugs you take every day right to your door

Many Aetna plans include our Aetna Rx Home Delivery mail-order pharmacy. It fills prescriptions for maintenance medicine. This type of medicine is used regularly, to treat conditions like arthritis, asthma, diabetes or high cholesterol. If you need this type of drug, you can get up to a 90-day supply, or the maximum supply allowed by your plan, and free delivery right to your mailbox.

You also get:

• Quick, confidential service

• Free standard shipping

• Pharmacists who check all prescriptions for accuracy and can answer questions any time

Use our specialty pharmacy for drugs that require special handling

Aetna Specialty Pharmacy is our in-house specialty pharmacy. It can fill your prescription specialty medicine. These types of drugs may be injected, infused or taken by mouth. Specialty medicine often needs special storage and handling. It must be delivered quickly. And a nurse or pharmacist should monitor you during your treatment. Use Aetna Specialty Pharmacy to get this medicine sent right to your mailbox. You also get:

• Free delivery that is reliable, secure and sent anywhere you choose

• Extra help when you need it — like injection training and side effect monitoring

• Proactive outreach to confirm your refills

• Free standard supplies

• Nurses and pharmacists who can help you 24 hours a day, every day

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.

Aetna plans do 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.

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

23

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 unless medically necessary

• Certain prescribed medications and supplies

• Nutritional supplements (other than as needed for PKU, prenatal vitamins, etc.)

• Smoking cessation aids or drugs unless required by California or federal law

• 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, the Aetna Preferred Drug List, cost estimates and more.

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

24

*All family members must be enrolled in the same plan.1 MayoClinic.com. “Oral health: A window to your overall health.” www.mayoclinic.com/health/dental/DE00001. February 5, 2011. Accessed August 2013.

Dental productsA 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

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

You can choose a dental benefits and insurance plan from any of our DMO, PPO, and Freedom-of-Choice plan designs.*

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

Dental Member Services 1-877-238-6200

25

*Discounts may not be available in all states.**Results will vary for different plan designs. Example does not include premiums.1Allaboutvision.com/eye-exam/importance.htm, April 2012. Accessed June 2013.2Jobson Vision Watch, Vision Council Member Benefits Report, June 2011.3Jobson Consumer Perceptions of Managed Vision Care Report 2011.

Vision See clearly with your Aetna vision plan

See why Aetna Vision Preferred is the right choice for you

• You can go where you want and buy what you want — in and out of network benefits included for most services.

• Customer service and self-service tools available seven days a week.

• Low out of-pocket vision expense.

• Value, choice, and convenience. You can choose any frame available — includes value-priced frames to high-quality designer frames with no confusing frame towers or formularies.

• Discounts on additional eyeglass purchases and noncovered products and services including LASIK.*

• You will receive a welcome packet that includes a member ID card, benefit summary and nearest provider locations.

Keep an eye on your health

We are committed to vision wellness, patient education and the associated preventive care.

Getting vision care can help lower unnecessary costs and improve your overall health. During a routine eye exam, all aspects of vision are checked, including the eye’s structure and how well the eyes work together. Annual eye exams allow eye care providers to monitor the health of the eyes and track changes that can occur from year to year. Besides measuring vision, eye exams help find early signs of certain chronic health conditions including diabetes, high blood pressure, heart disease, high cholesterol and eye disease.1

Discover the freedom to see any licensed vision office or retailer

Nearly 60 percent of eyewear dollars in the United States are spent at optical retailers.2 With Aetna Vision Preferred, you’ll have access to over 65,000 vision office and retailers, including3 LensCrafters®, Pearle Vision®, Sears® Optical , Target Optical® and JCPenney® Optical. Most with evening and weekend hours, including Sundays and located in or near shopping centers for added convenience. Can’t find your provider in our network? No problem. We provide reimbursements for most services outside the network so you are covered no matter who you see for your routine eye care.

Low out-of-pocket costs

Aetna Vision Preferred offers savings in or out of network for routine eye exams, contact lenses and eyeglasses, including prescription sunglasses and designer frames.

Sample out-of-pocket costs**

Retail price

Out-of-pocket costs with Aetna Vision Preferred

Savings with Aetna Vision Preferred

Exam $114.00 $10.00 $104.00

Frames $124.41 $0 $124.41

Lenses $ 83.00 $10.00 $ 73.00

Total $321.41 $20.00 $301.41

26Discounts may not be available in all states.

Aetna Vision Preferred – Premier plan

In network Out of network

In-network amount represents member copay, plan allowance or fixed discounted fee. Out-of-network amount represents the maximum reimbursement amount.

Exam – coverage allowed for one eye exam every rolling 12 months

Routine eye exam $10 copay $25 reimbursement

Standard contact lens fit/follow $40 discounted fee Not covered

Premium contact lens fit/follow 10% off retail Not covered

Frames – coverage allowed for one eyeglass frame every rolling 12 or 24 months (rates vary by frame frequency)

Any frame available at location $130 plan allowance $65 reimbursement

Lens – coverage allowed for one pair of prescription eyeglass lenses every rolling 12 months (in lieu of contact lenses per benefit period)

Single vision lenses $10 copay $20 reimbursement

Bifocal vision lenses $10 copay $40 reimbursement

Trifocal vision lenses $10 copay $65 reimbursement

Lenticular vision lenses $10 copay $65 reimbursement

Standard progressive lenses $75 copay $40 reimbursement

Premium progressive lenses20% discount off retail minus $120 allowance plus $75 copay = member out of pocket

$40 reimbursement

UV treatment $15 discounted fee Not covered

Tint (solid and gradient) $15 discounted fee Not covered

Standard plastic scratch coating $15 discounted fee Not covered

Standard polycarbonate lenses – child to age 19 $40 discounted fee Not covered

Standard polycarbonate lenses – adult $40 discounted fee Not covered

Standard anti-reflective coating $45 discounted fee Not covered

Contacts – coverage for one order of contact lenses every rolling 12 months (in lieu of eyeglass lenses per benefit period)

Conventional contact lenses $115 plan allowance $80 reimbursement

Disposable contact lenses $115 plan allowance $80 reimbursement

Medically necessary contact lenses $0 copay $200 reimbursement

Discounts

Available at in network locations

• 15 percent off balance over the plan allowance on conventional contact lenses

• 20 percent off balance over the plan allowance on frames

• Up to 40 percent off additional pairs of eyeglasses or prescription sunglasses

• 15 percent discount off retail or 5 percent discount off the promotional price for LASIK vision correction or PRK from U.S. Laser Network only. Call 1-800-422-6600

• 20 percent off noncovered items, including photochromic/transition and polarized lenses

• Receive significant savings after your lens benefit has been exhausted by ordering replacement contact lenses online at www.aetnavision.com


Aetna Vision Preferred – Plus plan








Any frame available at location $130 plan allowance $65 reimbursement








$25 reimbursement



Standard plastic scratch coating $0 copay $15 reimbursement

Standard polycarbonate lenses – child to age 19 $0 copay $35 reimbursement







Discounts









Aetna Vision Preferred – Basic plan








Any frame available at location $100 plan allowance $50








$30 reimbursement



Standard plastic scratch coating $15 discounted fee Not covered

Standard polycarbonate lenses – child to age 19 $40 discounted fee Not covered







Discounts








29

Life and disability insurance programs that do more

Nothing is more reassuring than knowing financial resources are available when you need them most. Our products provide your dependents financial support when it counts.

Financial security for your loved ones Aetna Group Term Life Insurance

Feel good about being prepared

Preparing for the unexpected is important to any financial goal. Helping to secure your loved ones’ futures is, too.

Choose the amount of life insurance you need

Life insurance offers your loved ones basic protection if you die. It can help pay your final expenses. Or it can help those you leave behind pay the mortgage, tuition and more. Your employer gives you a base amount of term life insurance.* You can choose to add more based on your financial needs. There is no medical exam for the base covered amount.

Hang on to your life savings

An illness that can end your life can also drain your life savings. The Accelerated Death Benefit is for those who have 24 months or less to live.** You can get up to 75 percent of your life insurance coverage amount while you’re still alive. Use it to help pay medical bills and other costs.

Take your life insurance with you

You can convert your group coverage to an individual life policy if you:

• Leave your job

• Lose benefits eligibility

• Get reduced benefits

You can even add an Accidental Death and Personal Loss rider at that time.

Tools and services to use today for a healthy, fulfilling life Aetna Life Essentials ProgramSM

Live well with discounts for your health, your wellness and your life

You can get discounts on the following types of products and services:

• Family care

• Travel

• Weight Management

• Medical alert

Take advantage of discounts on physical services

An important part of living longer is staying healthy. You have access to these discount programs:

• Aetna VisionSM

• Aetna HearingSM

• Aetna FitnessSM

• Waterpik®

Connect to the experts at no added cost

• Make preplanning your arrangements easier with our established partner, Everest Funeral Planning and Concierge Services.

• Talk to a financial counselor for securities and investment advice. Your loved ones can also call to learn how to invest money.

• Get easy access to the legal services and forms you need. We provide living wills, health care directives and durable financial power of attorney.

Get compassionate help to cope with end-of-life matters

You and your loved ones can talk to a master’s level licensed social worker who can help you make important decisions. You will also have access to our Compassionate CareSM website for checklists and other helpful information for people with a limited life expectancy.

Learn more at www.aetnalifeessentials.com.

Disability

A serious injury or illness can keep you out of work. For a long time. With no paychecks coming in. Are you prepared for that? Our disability plans protect your income when you need it most. This product will replace a portion of your salary to help you meet the day-to-day expenses like your mortgage and groceries when an illness or injury prevents you from working. Disability coverage ensures you have some income so you can focus on getting better, if possible. If you need to file a disability claim, Aetna Disability makes it easy for you, with 24-hour access to claim information online and tools to manage your benefits.

* Coverage options and features of life insurance policies vary between employers and states. Consult your Certificate of Insurance, Summary of Benefits or contact your Human Resources department for plan offering details.

** May be less than 24 months in certain states. Please refer to your plan documents.

Life insurance policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna).

30

Find quality doctors and specialists in the Aetna network

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

How to find your Nevada plan

When performing a search in DocFind, you will be asked to select a plan name. Some of the names of our Nevada 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

Aetna Value NetworkSM HMO AVN HMO

Open Choice® PPO PPO

Aetna HNOption (Open Access) HNOption

31

Dental DMO

Aetna Pediatric Dental Plan

Dental PPO

How to find your Nevada plan

Some of the names for our Nevada plans appear by their Aetna network names in DocFind. This screen shot is a quick reference guide to identify your plan.

32

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 the health information pages are not visible.

Nevada Employee Enrollment/Change Form

(2 - 50 Eligible Employees)

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 H.

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/Domestic

Partner

Add Dependent Child

Name Change

Other

Employee

Termination

Remove Spouse/

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

1. Medical Yes No Check One:

NV PPO – Plan Option:

Aetna HNOption – Plan Option:

Aetna Value Network HMO – Plan Option:

Indemnity – Plan Option:

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

2. Dental Yes No Enter plan number and name below.

Standard Plans:

Plan Number:

Plan Name:

Voluntary Plans:

Plan Number:

Plan Name:

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.

Yes No

Basic Life/AD&D Ultra®

Optional Dependent Life

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. Last Name, First Name, M.I.

Job Title

Primary Language Spoken (Optional)

Home Address

Apt. No.

City, State

ZIP Code

Work Address

City, State

ZIP Code

Home Telephone

( ) -

Work Telephone

( ) -

No. of Hours Worked Per Number of Dependents including Self

Per Week

Salary

$

Hourly

Weekly

Monthly

Check One

Full-Time 1099 Seasonal COBRA

Part-Time Retiree Temporary Union

Marital Status

Single Married Divorced

Widowed Legally Separated

GR-68900-18 (9-13) 1 NV R-POD

How to complete the enrollment form

Be sure to complete your enrollment form thoroughly.

The information noted below are frequently overlooked.

1. Indicate your date of hire.

2. Select the medical plan(s) offered by your employer. If dental plans are offered, select your dental plan next.

3. Enter your doctor’s (and dentist’s if enrolling in a DMO plan) ID number if enrolling in an HMO plan.

4. Sign and date to complete the form.

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

C. Individuals Covered - List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if

necessary. NOTE: Enter Domestic Partner ONLY if your employer has elected that coverage.

NOTE FOR MEDICAL AND DENTAL COVERAGE: While the Federal Patient Protection and Affordable Care Act mandates coverage of dependent

children up to age 26, your plan may allow coverage beyond age 26. Some exceptions apply. Please refer to your plan documents or contact your

benefits administrator.

If any person has used tobacco products (cigarettes, pipe, cigars, snuff, or chewing tobacco) an average of four or more times per week

within the past six months, check below. Religious or ceremonial uses of tobacco (for example, by American Indians and Alaska Natives)

are exempt. This only applies to enrolling person(s) that meet or exceed the state-defined legal tobacco age.

1

(A)dd

(C)hange

(R)emove

Employee Name (Last, First, M.I.)

Sex (M/F)

Social Security Number

Birthdate

(MM/DD/YYYY)

/ /

Coverage Election

Medical Dental Life/Disability

Primary Office ID Number (if

applicable)

Current

Patient

Yes

Dentist Office ID Number (if applicable)

Current

Patient

Yes

Tobacco Use Yes No Currently participating in Quit Smoking Program Yes No

2

(A)dd

(C)hange

(R)emove

Name (Last, First, M.I.)

Spouse Domestic Partner

Sex (M/F)


Birthdate

(MM/DD/YYYY)

/ /

Coverage Election

Medical Dental Life


applicable)

Current

Patient

Yes


Current

Patient

Yes

Tobacco Use Yes No Currently participating in Quit Smoking Program Yes No

3

(A)dd

(C)hange

(R)emove

Name (Last, First, M.I.) Child Stepchild Other

Sex (M/F)


Birthdate

(MM/DD/YYYY)

/ /

Coverage Election

Medical Dental Life


applicable)

Current

Patient

Yes


Current

Patient

Yes

Tobacco Use Yes No Currently participating in Quit Smoking Program Yes No Incapacitated Yes No

4

(A)dd

(C)hange

(R)emove


Sex (M/F)


Birthdate

(MM/DD/YYYY)

/ /

Coverage Election

Medical Dental Life


applicable)

Current

Patient

Yes


Current

Patient

Yes


5

(A)dd

(C)hange

(R)emove


Sex (M/F)


Birthdate

(MM/DD/YYYY)

/ /

Coverage Election

Medical Dental Life


applicable)

Current

Patient

Yes


Current

Patient

Yes


6

(A)dd

(C)hange

(R)emove


Sex (M/F)


Birthdate

(MM/DD/YYYY)

/ /

Coverage Election

Medical Dental Life


applicable)

Current

Patient

Yes


Current

Patient

Yes


GR-68900-18 (9-13) 2 NV

Conditions of Enrollment On behalf of myself and the dependents listed on Page 2, I agree to or with the following:

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

● Aetna Value Network HMO plans: Aetna Health Inc.

● Aetna HNOption plans: Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company

● Aetna PPO plans: Aetna Life Insurance Company

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

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

eligible employee enrollment form and employer applications have been accepted and approved by Aetna. Even if this enrollment form is

approved, any misstatements or omissions may result in future claims being denied and the policy or my coverage under the policy being

rescinded or reevaluated, as of the effective date, for eligibility and rating purposes.

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 Aetna or its agent information concerning the medical history, prescription utilization history, services or treatment

provided to anyone listed on this Enrollment/Change Form, including those involving mental health and substance abuse. 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/domestic partner and competent

adult dependents and I have obtained their consent to those terms. This authorization will remain valid for the term of the coverage and so long

thereafter as allowed by law. I understand that I am entitled, as is any authorized representative that I may designate, to receive a copy of this

authorization upon request and that a photocopy is as valid as the original.

4. Authorizations signed for the purpose of collecting information in connection with this enrollment form 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 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. The information, as well as other personal or privileged information, subsequently collected by the insurance institution or agent

may, in certain circumstances, be disclosed to third parties without authorization. A right of access and correction exists with respect to all

personal information collected. Further disclosures required by Nevada law will be furnished to the policyholder upon request. Personal

information may be collected from persons other than the individual or individuals proposed for coverage.

5. 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.

6. I understand and agree that providers and vendors are independent contractors in private practice and are neither employees nor agents of

Aetna or its affiliates. The availability of any particular provider cannot be guaranteed and provider network composition is subject to change.

7. I understand and agree that, with certain exceptions described in the plan documents, HMO 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, or by the participating specialist,

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

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 Nevada 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 at the regular place of business.

Misrepresentation: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of

defrauding the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Employee Signature

X

Employee E-mail Address

Date (Month/Day/Year)

GR-68900-18 (9-13) 4 NV

D. Dependent Information

List any dependent in Section C living at another address.

Name Address

For Dependent Life: If age 19 and over and a full-time student, provide the following:

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. 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

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. Case management is a process of identifying individuals with certain medical conditions associated with complex health care needs and

helps us better provide you with any care you may need.)

AIDS

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

Congestive Heart Failure

COPD using oxygen

Cor Pulmonale

Defibrillator /AICD/ Implantable Cardioverter

End of Life/Hospice

Hypertensive Heart Disease

Hypertensive Renal Disease

Multiple Sclerosis

Muscular Dystrophy

Myasthenia Gravis

Paralysis

Paraplegic

Pregnant - high risk or multiple births

Quadriplegic

Name of Individual Condition(s)

H. Declination/Waiver of Coverage - To be completed if medical, dental and/or life/life disability package coverage is declined or refused by

an eligible employee and/or their eligible family members.

1. Medical Coverage Declined for:

Myself Children

Spouse/Domestic Partner

2. Dental Coverage Declined for:

Myself Children

Spouse/Domestic Partner

3. Coverage Declined for:

Life/Life & Disability Package Plan

Optional Dependent Life

Reason for declining coverage:

Spouse/Domestic Partner group coverage

Parental group coverage

Medicare

Medicaid

Retiree coverage

AHCCCS

Another group plan provided by my employer

COBRA coverage

Insurance through another job

TRICARE Military Coverage

Individual coverage – On or Off Exchange

Indian Health Services

Do not want

Other

I acknowledge I have been given the right to apply for this coverage, however, I am electing not to enroll. By declining this group coverage I

acknowledge that I 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 or your dependent(s).

Employee Signature X

Date (Month/Day/Year)

GR-68900-18 (9-13) 3 NV

The above application/enrollment form includes changes required by the federal Affordable Care Act. This form is pending regulatory review and approval and subject to change.

1

2

2

3

4 4

5

33

Your member ID card

After you enroll in an Aetna medical plan, 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.

1. Plan in which you are enrolled.

2. Additional information, including precertification number for mental health and substance abuse services.

3. Call this number to speak with a Member Services representative.

Printed on biodegradable card stock (bio PVC). One card for up to five family members. One card combines medical, dental and Rx information.

2

1

3

You don’t need an ID card for Aetna Dental

If you enroll in a dental plan, but not a medical plan, you will not receive an ID card.

How will my dentist know I’m an Aetna member? When you go to your dentist, tell the office your name, date of birth and Member ID number (or your Social Security number).

But what if I want a card? Easy. Just print a card by going to the secure member website at www.aetna.com. You can print a card for you and your dependents listed above.

What if I haven’t signed up for the member website yet? No worries. Signing up is simple and free. And it’s password-protected. Just go to www.aetna.com and click on Log In/Register to sign up.

Contact informationMember Services

Medical

For benefits questions or claims inquiries for Aetna AVN HMO or the Aetna HNOption plan. 1-866-529-2517

Claims address: Aetna P.O. Box 14079-4079 Lexington, KY 40512

For benefits questions or claims inquiries for Aetna PPO Plans, or Aetna indemnity plans 1-888-802-3862

Claims address: Aetna P.O. Box 14079-4079 Lexington, KY 40512

Dental

1-877-238-6200

Prompt 1 (Dental plan member) Prompt 2 (Dental care provider)

Claims address: Aetna P.O. Box 14094 Lexington, KY 40512-4094

Life

1-800-523-5065

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

Pharmacy

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

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

Claims address: Aetna Pharmacy Management P.O. Box 14024 Lexington, KY 40512-4024

Mail-Order Drugs

1-866-612-3862

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

To track and order Rx refills: www.aetnarxhomedelivery.com

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

Aetna Natural Products and Services discount program, Aetna Fitness discount program, and DocFind

Visit Aetna Navigator for details and information on how to get started.

Aetna Navigator

Your secure Aetna Navigator member website is available 24 hours a day, seven 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.

34

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, dental and life insurance plans contain exclusions and limitations. Not all health, dental and disability services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional.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. 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 the Aetna 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. 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.

www.aetna.com

©2014 Aetna Inc. 14.05.902.1-NV (9/14)

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

We look forward to welcoming you and your family as our newest members!

Contact information:

HMO Member Services 1-866-529-2517

PPO Member Services1-888-802-3862

visit www.aetna.com

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