ColoradoSupplementtotheSummaryofBenefitsandCoverageForm

AetnaLifeInsuranceCompany

NameofCarrier

AetnaChoice®POSII-HSA

NameofPlan

LargeEmployerGroupPolicy

PolicyType

TYPEOFCOVERAGE

1.TYPEOFPLAN / POS
2.OUT-OF-NETWORKCARECOVERED?1 / Yes;butpatientpaysmoreforout-of-networkcare
3.AREASOFCOLORADOWHEREPLANISAVAILABLE / PlanisavailablethroughoutColorado.

SUPPLEMENTALINFORMATIONREGARDINGBENEFITS

ImportantNote:Thecontentsofthisformaresubjecttotheprovisionsofthepolicy,whichcontainsallterms,covenantsandconditionsofcoverage.ItprovidesadditionalinformationmeanttosupplementtheSummaryofBenefitsandCoverageyouhavereceivedforthisplan.Thisplanmayexcludecoverageforcertaintreatments,diagnoses,orservicesnotspecificallynoted.Consulttheactualpolicytodeterminetheexacttermsandconditionsofcoverage.

Description / Whatthismeans.
4.DeductiblePeriod / CalendarYear / CalendaryeardeductiblesrestarteachJanuary
5.AnnualDeductibleType / Single/Non-SingleCoverage / SinglemeansthedeductibleamountyouwillhavetopayforallowablecoveredexpensesunderthisHSA-qualifiedhealthplan when youaretheonlyindividualcoveredbytheplan.Non-singleisthe deductibleamountthatmustbemetbyoneormorefamilymemberscoveredbythisHSA-qualifiedplanbeforeanycoveredexpensesarepaid.
6.Whatcancerscreeningsare / ProstateCancerScreening / AgeandFrequencyschedulemayapply
covered? / CervicalCancerScreening / AgeandFrequencyschedulemayapply
BreastCancerScreening / AgeandFrequencyschedulemayapply
ColorectalCancerScreening / AgeandFrequencyschedulemayapply

LIMITATIONSANDEXCLUSIONS

7.Periodduringwhich
pre-existingconditionsarenotcoveredforcoveredpersonage19andolder2 / Notapplicable,plandoesnotimposelimitationperiodsforpre-existingconditions.
8.Howdoesthepolicydefinea “pre-existingcondition”? / Notapplicable,Plandoesnotexcludecoverageofpre-existingconditions.
9.ExclusionaryRiders.Canan individual'sspecific,
pre-existingconditionbeentirelyexcludedfromthepolicy? / No

USINGTHEPLAN

IN-NETWORK / OUT-OF-NETWORK
10.Iftheproviderchargesmorefora coveredservicethantheplannormallypays,doestheenrolleehavetopaythedifference? / No / Yes,refertoyourcertificateofcoveragefordetails.
11.Doestheplanhaveabindingarbitrationclause? / No

Questions:Call

1-888-982-3862,TDD1-800-628-3323(hearingimpairedonly)orvisit

Ifyouarenotsatisfiedwiththeresolutionofyourcomplaintorgrievance,contact:

Endnotes:

ColoradoDivisionofInsuranceConsumerAffairsSection

1560Broadway,Suite850,Denver,CO80202

Call303-894-7490(instate,tollfree:800-930-3745)Email:

1“Network”referstoaspecifiedgroupofphysicians,hospitals,medicalclinicsandotherhealthcareprovidersthisplanmayrequireyoutouseinorderforyoutogetanycoverageatallundertheplan,orthattheplanmayencourageyoutousebecauseitmaypaymoreofyourbillifyouusetheirnetworkproviders(i.e.,goin-network)thanifyoudon't(i.e.,goout-of-network).

2Waiverofpre-existingconditionexclusions.Statelawrequirescarrierstowaivesomeorallofthepre-existingconditionexclusionperiodbasedonothercoverageyourecentlymayhavehad.Askyourcarrierorplansponsor(e.g.,employer)fordetails.

ColoradoAccessDisclosure:

Aetnamaintainsandmakesavailabletointerestedpartiesuponrequestamanagedcarenetworkaccessplanonitsbusinesspremises.Themanagedcarenetworkaccessplandemonstratesthemanagedcarenetworkcontainsanadequatenumberofaccessibleacutecarehospitals,primarycareproviders,andspecialistsavailabletoprovidecoveredhealthcareservices.Amongotherthings,theaccessplan describesAetna'sprocessformonitoringandassuringonanongoingbasisthesufficiencyofthenetworktomeetthehealthcareneedsofplanenrollees.

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