14.07.901.1-TX (2/04)

Administrative HandbookTEXAS (effective 9-1-03)

Small Business Employers

2 - 50 eligible employees

WELCOME

Welcome to Aetna. We are excited you have chosen Aetna

and look forward to providing you with a level of service that

demonstrates our commitment to improving the quality of

healthcare.

This handbook provides a summary of the administrative

information you need to help you administer your Aetna plan(s).

It is important for the successful administration of your plan(s) that

you read and understand this information, particularly the necessity

of timely and accurate submission of data and other information as

described in the handbook.

As you read through this handbook, please note that you may

encounter specific terms or references that do not apply to the plan

or benefits you have selected. The actual terms of your group plan

will be set forth in the plan documents (Schedule of Benefits,

Certificate of Coverage, Evidence of Coverage, Group Agreement,

Group Insurance Certificate, Booklet, Booklet-certificate, Group

Policy) issued to you by Aetna. As such, the information contained

in this handbook is in no way part of, nor a waiver to, the actual

terms of your group plan or any other agreement you may have

with Aetna.

Thank you for choosing Aetna.

Sincerely,

Aetna Small Group

1

Introduction .................................................................................................................. 2

Contacts........................................................................................................................3

Eligibility ................................................................................................................. 4 - 6New Hire EligibilityBenefit Waiting PeriodOpen EnrollmentLate ApplicantsEligible Members of the FamilyHMO Dependents living away from homeQualifying EventsEnrollment Change FormsPrimary Care Selection

State Continuation........................................................................................................ 7

COBRA .......................................................................................................................... 8

Medicare ........................................................................................................................ 9

Aetna Member ID Cards ...................................................................................... 10 - 11

Billing .................................................................................................................. 12 - 17

Tips For Your Employees ................................................................................ 18 - 20Technology SolutionsSpecial ProgramsDiscount Programs

Supplies ..................................................................................................................... 21Enrollment/Change Form for TexasHow to Use DocFindAetna NavigatorVision One Discount ProgramAlternative Healthcare ProgramFitness Program

Contents

2

As the benefits administrator you may contact theAetna Small Group Service Center, a group ofindividuals trained to address your unique concerns.This group of individuals will be able to answer yourquestions regarding enrollment, billing and groupsetup. In addition, you may order replacementmembership cards for employees or additionalenrollment supplies.

Call the Aetna Small Group Service Centerat 1-866-899-4379 during the hours of 8:00 a.m.to 5:00 p.m. CST, Monday through Friday.

Member questions should be directed to ourMember Services department. We suggest thatyour employees speak with a Member Servicesrepresentative by calling the toll-free telephonenumber listed on their identification (ID) cards. TheMember Services department is open Mondaythrough Friday, 8:00 a.m. to 6:00 p.m. CST. If asituation requires your involvement, call the AetnaSmall Group Service Center for prompt resolution.

Introduction

GLOSSARY

Here are some terms you will encounter as youreview this handbook:

Benefit Waiting Period - the benefit waitingperiod is the probationary period or the amountof time a new hire must wait to become eligiblefor coverage with Aetna. Determined by theplan sponsor at the time benefits are electedand set up.

HMO – Health Maintenance Organization orAetna Primary CareTM Plan

Indemnity – Traditional or Aetna DirectTM Plan

MOD – Mail order drug

Out of Area Dependent – Dependent who doesnot live in an Aetna HMO Service Area

Your employees should consult their memberhandbooks and/or their applicable plan documentsfor clarification of how the plan works; for coveredservices, limitations and exclusions; and for adescription of the Aetna grievance and appealsprocess.

Aetna has a process that gives members the addedoption of requesting an objective and timely externalreview of certain coverage denials for memberscovered under our insured products. Youremployees may call Member Services for moreinformation.

PCP – an HMO term for primary care provider.A primary care provider (PCP) must bedesignated to ensure benefits are paid. PCPsare Family Practitioners, General Practitioners,Internists and Pediatricians.

Primary provider – a PPO term for physician.To receive maximum benefits, an employeeshould visit physicians that are preferred or inthe network.

PPO – Preferred Provider Organization or AetnaChoiceTM Plan PPO

POS – Point of Service or Aetna ChoiceTM PlanPOS

Provider – the physician chosen to provide care

Traditional products – PPO and indemnitymedical, dental, life and disability plans

How can the Aetna Small Group Service Center help you?

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8:00 a.m. to 5 p.m., Monday through Friday 1-866-899-4379 1-877-362-0868 faxfor questions concerning billing or enrollment. option 1

For regular mail: ........................................................................... Attn: Plan Sponsor ServicesP. O. Box 91507Arlington, TX 76015-0007

For overnight mail: ....................................................................... Attn: Plan Sponsor Services4300 Centreway PlaceArlington, TX 76018

For benefit questions or claims inquiries for:MEDICAL ..................................................................................... HMO Traditional

1-888-702-3862 1-888-802-3862Aetna AetnaP. O. Box 1125 P. O. Box 981204Blue Bell, PA 19422 El Paso, TX 79998

DENTAL ....................................................................................... 1-877-238-6200AetnaP. O. Box 14066Lexington, KY 40512-4066

LIFE ............................................................................................. 1-800-523-5065Aetna Life InsuranceP. O. Box 14547Lexington, KY 40512-4547

DISABILITY ................................................................................. 1-866-282-8495 LTD (Long Term Disability)1-866-226-8143 STD (Short Term Disability)P. O. Box 1480Portland, OR 97207

PHARMACY ................................................................................. 1-800-238-6279 or 1-800-AETNA RXAetna Pharmacy ManagementP. O. Box 398106Minneapolis, MN 55439-8106

Mail Order Drug .............................................................. 1-866-612-3862Aetna Rx Home DeliveryP.O. Box 417019Kansas City, MO 64179-9892

More information about our Special Programs can be accessed through our website at www.aetna.com! Vision One® Discount Program ! Informed Health® Line

Call for closest eyecare provider 24 Hour Nurse Help Line1-800-793-8616 1-800-556-1555

! Alternative Healthcare Programs ! Fitness Program! DocFind ! Aetna Navigator

How to Reach Us

PLAN SPONSOR SERVICES

MEMBER SERVICES

OTHER PROGRAMS

4

Employee EligibilityWhen your company enrolled with Aetna, youselected eligibility rules to reflect your company’spolicy. You may confirm these rules or any othereligibility concerns with the Aetna Small GroupService Center by calling anytime between8:00 a.m. and 5:00 p.m. CST, Monday throughFriday. The toll free number is 1-866-899-4379.

Benefit Waiting PeriodThe benefit waiting period is the probationary periodor the amount of time a new hire must wait tobecome eligible for coverage with Aetna. Thiswaiting period can only be changed annually at thetime of your plan renewal. If you selected aprobationary period, the employee’s eligibility date isthe first of the month after they finish serving theirprobationary period. If there is no probationaryperiod, the employee eligibility date will be the firstof the month following their hire date. In order to beeligible for coverage, the employee must sign andreturn the enrollment form within 31 days of theireligibility date. Otherwise, the employee will betreated as a “late enrollee” and will be subject to therequirements outlined in the Late Applicant section.

All new employees are required to meet their benefitwaiting period. Waiving the benefit waiting period isnot permitted. If an employee is rehired within12 months of terminating coverage under your planwith Aetna, the employee does not need to meet thebenefit waiting period again.

Open EnrollmentThe open enrollment period is the time of year whenyou and your employees can reevaluate your benefitneeds and select the plan(s) that best meet yourneeds for the following year.

The timing of the open enrollment greatly affects theservice your members receive. By conducting theenrollment at least 30 days prior to your effectivedate, ID Cards should be received prior to theeffective date and your bill should reflect the newchanges. Your employees can make informeddecisions by having sufficient time to learn about alltheir benefit options.

Late ApplicantsMedical applicants will be deferred to the next plananniversary date of the group. A new enrollment formwill be required.

Life and Disability applicants are subject toMedical Underwriting.

Dental applicants can be enrolled at any time butare limited to Preventive and Diagnostic services forthe first 12 months (24 months for Orthodontics).

Eligibility

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Eligible Members of the FamilyWhen an employee joins Aetna, his/her spouse anddependent children are eligible to join the plan. Ifeligible dependents do not sign up at openenrollment or when they first become eligible, theymust wait until the next open enrollment period.

Eligible employees are those employees who arepermanent and work on a full-time basis with anormal work week of at least 30 hours for Texas(according to State Legislation) and who have metany authorized waiting period requirements. Thisincludes a partner of a partnership, sole proprietor orindependent contractor if included as an employeeunder the health benefits plan of a small employer.Employees who do not meet the definition of apermanent full-time employee will not be eligible. Ifboth husband and wife work for the same company,each must enroll separately as an employee.

Retirees are not eligible for coverage.

Parents of an employee or spouse are not eligiblefor coverage.

Individuals cannot be covered as an employee anddependent under the same plan, nor may childreneligible for coverage through both parents becovered by both parents under the same plan.

Eligible dependents include an employee’s spouseand unmarried children from birth to age 19. (seestate regulations for Texas Employers).

Dependents are not eligible for coverage until theemployee becomes eligible for coverage, and mustenroll in the same benefit option as the employee.

Newborn children are covered for 31 days from thedate of birth. To continue coverage beyond thisinitial period the employee must enroll the newbornin the plan within 31 days from the date of birth:a premium increase will result if the enrollee did nothave other children enrolled as dependents. Thenewborn’s social security number should beprovided when assigned, but is not necessary forenrollment.

Domestic Partners are not considered eligibledependents.

Disabled dependent children over the applicableage limit who cannot support themselves due to adisability may be covered as a dependent. Toqualify for this exception, the condition must haveexisted prior to the child’s reaching the applicableage limit and must be documented by a physician.Approval from Aetna is required.

Dependent eligibility, including grandchildren, mayvary by state regulation and the plan design youhave purchased. Consult your Plan Documents fordetails.

State Regulationsfor Texas Employers! Medical and dental plans are to provide coverage

for dependents (including eligible grandchildren),until the age of 25. There is no requirement thatthe dependent child attend school.

! Coverage is required for the child of adependent child (grandchild). The grandchildmust be primarily dependent upon the employeeor member for support, for federal income taxpurposes. It is not necessary that the grandchildreside with the employee. Proof of dependencymay only be required at the time of enrollment.

Eligibility continued

6

HMO Dependentsliving away from homeDependents of HMO members who reside in one ofour HMO service areas receive the same benefits ofthe plan by selecting a PCP near their residence orschool. Dependents who reside outside an AetnaHMO service area are covered for emergency careonly, including follow-up of emergencies andspecialty care when medically necessary.

Qualifying EventsIt is important to notify Aetna when an employeewishes to add him or herself and/or deletedependents due to a change in family status or anevent such as the loss of coverage. Becauseemployee and dependent additions may affect yourpremium and your bill, you must forward to theAetna Small Group Service Center a completedenrollment form within 31 days of the qualifyingevent. Changes requested after the 31 dayperiod are late and follow the rules for lateapplicants.

Loss of other coverage allows an employee and/ordependent(s) to enroll outside of Open Enrollment.To enroll, the subscriber must submit proof ofprevious insurance coverage, and a completedenrollment form within 31 days of the date of loss ofcoverage.

Enrollment/Change FormsThe enrollment form is used to enroll and terminatesubscribers, to process changes in family status,such as the birth of a child, removal of a dependent,a marriage or address change.

You should review all completed enrollmentforms and submit to Aetna within 31 daysof the event with the exception of terminationswhich must be reported within 30 days.

For proper processing and timely issuing of IDcards, confirm that the form includes the followinginformation before submitting the form to Aetna.! Group/Control Number! Employer name! Plan option (if applicable)

! Effective date! Employee and Dependent Names! Employee Address! Employee / Dependent(s) Date(s) of Birth! Applicable dependent relationship information! Social Security numbers! Explanation (if applicable) for dependents having a

different last name! Provider selections (if applicable)! Employee Hire Date! Employee signature

NOTE: When enrolling new hires or submitting achange for an existing subscriber or member,always include your “Control or Group number,”which is a numeric code for your company, and the“subgroup number or plan number,” which indicatesthe specific benefits level or company classification.

Send these forms directly to the Aetna Small GroupService Center to expedite enrollment processing.Refer to the contact section of this manual for theaddress.

Do not include the enrollment/change formswith your payment. The payment is received at abank lock box. The processing of your correspon-dence will be delayed by mailing it to that location.

Primary Care PhysicianSelectionIn some states, HMO’s are required to designate aparticipating primary care physician (PCP) formembers who do not select a PCP at the time ofenrollment. The selection is a random processbased on the PCP’s proximity to the member’sresidence, allowing the member to access the fullrange of covered benefits under the plan. Membersare free to change this selection at any time bycalling Member Services at the toll-free number ontheir ID card. However, you should encourage youremployees to select a PCP for themselves and anyeligible dependents at the time of enrollment.Contact your broker, or the Aetna Small GroupService Center if you have questions about thispolicy.

Eligibility continued

7

State Medical ContinuationTexasState medical continuation is available to all sizegroups in Texas. If a group is eligible for COBRA,state continuation can be elected after COBRA isexhausted. For more information about statecontinuation requirements contact theTexas Dept. of Insurance at 1-800-252-3439 orhttp://www.tdi.state.tx.us/.

State Continuation

*The group’s size may vary by state. Consult your Plan Document for state-specific continuation options.

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COBRAThe Consolidated Omnibus Budget ReconciliationAct of 1985 (COBRA) and subsequent amendmentsrequire employers with 20 or more employees whoprovide group health coverage to allow certainindividuals to continue coverage at the individual’sexpense when coverage terminates because of aspecified qualifying event.

A summary of the general rules and proceduresgoverning continuation of coverage under COBRAis provided below. It does not discuss every possiblesituation, which may bear on your obligations in thisarea. For more information, contact the Departmentof Labor (DOL) COBRA for information http://www.dol.gov/dol/topic/health-plans/cobra.htm.

As COBRA is an employer-directed law, it isstrongly recommended that you consult yourown legal counsel regarding your compliancewith COBRA. The following is not intended as asubstitute for the law itself or for legal or otherprofessional advice.

Qualifying EventsCOBRA provides that continuation of coverage mustbe made available to employees, their spouses andtheir dependent children who would otherwise losecoverage under the group health plan because of! termination of employment! employee’s enrollment into Medicare! reduction in hours that results in a loss of

coverage! death of the employee! divorce or legal separation

Dependent children may be eligible for continuationwho become ineligible for coverage under aprovision of the employer’s group health plan (e.g.,loss of student status or attainment of maximumage for coverage).

Effective DateContinuation of group coverage commences on thedate of the qualifying event if the plan so provides.The maximum period of COBRA continuation ofgroup coverage varies from 18 months to 36months based on the type of qualifying event andthe participant.

NOTE: Whenever a qualifying event occurs wherean employee or dependent loses coverage, youmust notify Aetna to terminate benefits for theemployee and/or dependent(s). Aetna reserves theright to limit credit for terminations not reported in atimely manner.

Enrollment in State Continuation/COBRAUse the enrollment/change form to notify Aetna ofthose employees, spouses and dependents whoelect to continue coverage. The completed formmust include the qualifying event, the effective date,and the maximum length of continuation. Failure toinclude the necessary information will result in thedelay of the processing of the application until therequired information is submitted. Applications forCOBRA and/or state continuation should be filledout completely and signed by the qualifiedbeneficiary.

You should send the completed authorizedenrollment form to Plan Sponsor Services as soonas a timely election has been made.

Termination of State Continuation/COBRAUse an enrollment/change form to notify Aetna thatthe member’s period of continuation has ended.Failure to submit this form to Aetna on a timelybasis will not modify the date coverage is scheduledto terminate as prescribed by law and/or contract forthe particular qualifying event, i.e., 18/36 months.Any terminations will be retroactive to thattermination date.

RatesYou, the plan administrator, are responsible forgiving your employees information about rates.Employees cannot receive these rates throughAetna.

COBRA

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Medicare is a federal health insurance programprimarily established for people age 65 and overand qualified disabled individuals who meet certaineligibility requirements. When an employee ordependent spouse approaches age 65, the AgeDiscrimination and Employment Act (ADEA)requires that an employer counsel these individualsregarding Medicare benefits. Employers shouldensure that Individuals meeting this criteria areinformed of eligibility requirements, how to apply forMedicare, and how Medicare coverage operates inrelation to your group health plan. Please consultwith your legal counsel regarding your Medicareresponsibilities.

Aetna considers a person eligible for Medicare ifhe/she is covered under it or is not covered under itbecause of having refused it, having dropped it, orhaving failed to make proper request for it. Pleaserefer to your plan documents for the specific termsthat apply to your group plan.

The following general guidelines will assist you indetermining when an individual is eligible forMedicare primary health coverage. The followingare some general guidelines and are not intendedas a substitute for the group plan documents, or forthe law itself or for legal or other professionaladvice.

Aetna Primary or Medicare Primary refers towho pays claims first, Aetna or Medicare.

If your group plan is subject to the Tax Equityand Fiscal Responsibility Act (TEFRA):Aetna is primary for the employee and dependent ifthe employee is active. (See Disability* and End-Stage Renal Disease** remarks)

If your group plan is not subject to the TaxEquity and Fiscal Responsibility Act (TEFRA):Aetna is secondary for employees and dependentsunder 65 years of age.

Medicare is primary for employees and dependents65 years of age or older. (See Disability* and End-Stage Renal Disease** remarks)

Retirees: Retiree coverage is not available.

Note: Plan Sponsor Services and Member Serviceswill provide assistance based on the currentinformation available to them in our systems. Youare required to provide Aetna with verification thatthis information is correct on an annual basis.Please be sure to provide all requested informationfor Employer Verification and Medicare SecondaryPayor to Aetna in a timely manner to maintain theaccuracy of your plan information. Please contactyour broker, or the Small Group Service Center ifyou have questions.

Medicare

* Disability: If the member is entitled to Medicare due to disability, there are various factors that areconsidered in determining who the primary payor is. These include, but are not limited to, the type ofdisability, age and retirement status. There are circumstances that would require Aetna to be primary toMedicare, if the person is on Medicare due to disability. Please contact Member Services using the toll-freenumber on your ID card for assistance.

**End-Stage Renal Disease: Different laws govern determination of primary payor if the member has End-Stage Renal Disease. Please contact Member Services using the toll-free number on your ID card forassistance.

10

An ID (identification) card lists pertinent informationabout the plan under which the employee/dependentis enrolled. A member must present the ID card toaccess care from a medical, dental or pharmacyprovider.

Timely submission of completed enrollment formswill expedite ID card processing.

After the Employee Enrollment Form is signed bythe employee, give a copy to the employee, keep acopy for your records and mail the original to Aetna.The ID cards are usually mailed within 30 days ofour receipt of the Enrollment Form.

A subscriber who has a covered spouse or partnerwill automatically receive two copies of their familyID card; medical and dental cards will be separateso a family with both coverages will receive bothmedical and dental family cards. The ID card willhold up to five names. Larger families will receive asecond card or a set of cards.

A subscriber who is enrolled in an HMO or DMO planand has covered dependents will receive individualmember ID cards.

Families that wish to obtain additional cards (i.e, fora college student) or make changes may requestthem through Aetna Navigator or by calling MemberServices.

Aetna NavigatorYour employees will be able to view and print a copyof their eligibility form for use until their member IDcard is received. Additional information about AetnaNavigator can be found under the Special Programssection of this manual. A few of the options availablein Aetna Navigator are listed below.! search personalized DocFind - English and

Spanish versions available! check claim status! change PCP! request ID cards! contact Member Services! Hospital Comparison Tool

PharmacyMembers with prescription drug coverage mustpresent their ID cards to the pharmacy whenobtaining a prescription. In the event that a memberdoes not present an ID card, the participatingpharmacist may call our provider hotline at 800-AETNA-RX (800-238-6279), 24-hours a day, 7 daysa week to verify the necessary information.

Until members receive their Aetna ID cards, theyshould have their prescriptions filled at participatingpharmacy and pay for the prescription. Oncemembers receive their ID cards, they should submita copy of the receipt with their ID number or SocialSecurity number clearly marked on the PrescriptionDrug Claim Form for reimbursement. Submit theclaim form to:

Pharmacy ManagementP.O. Box 398106Minneapolis, MN 55349-8106

Other ID Card InformationThrough the year, enrollment changes are submittedby you to Aetna. Certain changes will cause an IDcard to generate. They include:! Addition of new employee! Provider Change! Addition of new dependent(s)! Effective Date Change! Name Change! ID Card Request

Replacement ID cardsID cards are not automatically generated uponrenewal, unless a change in benefit plan occurs.

Member ID Cards

11

Member ID Cards continued

Dental:DMO (Dental Maintenance Organization) PDN (Preferred Dental Network)

Below are samples of ID Cards:

Note: there are no Member ID Cards for the Indemnity / Aetna DirectTM Plan.

Medical:HMO / Aetna Primary CareTM Plan PPO / Aetna ChoiceTM Plan PPO

HMO

ID# MEMBER NAME

BB0000A JOHN DOEROSENBERG, GEORGE , MD

DR XXX-XXX-XXXX 000000

MEMBER SERVICES 888-247-1024PRECERTIFICATION 800-245-1206BEHAVIORAL HLTH VENDOR 800-424-5707

GRP: 00000 VALID: 02/01/2002 RX

PPO NAP

ID W1072 8375001 JOHN SMITH02 SALLIE SMITH03 JOHNNIE SMITH

MEMBER SERVICES 1-888-802-3862 O/V $ 15.00

ANNUAL RENEWAL DATE: 12/01/03 PAYOR NUMBER 60054 0322

GRP: 000017-20-000 BIN# 010502 RX

DMO®

ID W1074 2957301 MARY DOE PCD: NO ELECTION

MEMBER SERVICES 1-877-238-6200 O/V $ 5.00

PAYOR NUMBER 60054 0322

GRP: 000017-20-000 BIN# 010502 RX

PDN

ID W1072 8375001 JOHN SMITH02 SALLIE SMITH03 JOHNNIE SMITH

MEMBER SERVICES 1-877-238-6200

PAYOR NUMBER 60054 0155

GRP: 930017-31-000

DR $ ER $$SP $ HO %/AAS % UC 50MH 30-20VRX20/40/70

12

Aetna billing statements are generated on the 15th ofeach month for the following month for customerswith an effective date of the first (1st). Statementsare generated on the 1st for customers with aneffective date of the 15th.

Upon receipt, review your bill for accuracy. If youfind discrepancies on the bill, you should call theAetna Small Group Service Center at 866-899-4379promptly so they can be resolved in a timely manner.Aetna’s billing and coverage is based on themember information provided to us by you.Therefore, you are responsible for notifying us in atimely manner of any changes in coverage and/ormember status. Employers are responsible forpayments for the coverage provided by Aetna whenmember terminations are not reported in a timelymanner.

Please pay the billed amount. Backupdocumentation must be sent with the bill. Thisdocumentation can be a copy of the bill withnotations on it or a separate document. If sending aseparate document, please be sure to include yourcustomer account number.

Payments should be mailed by using the windowenvelope provided with your statement. Encloseyour check, the payment stub and all applicabledocumentation to ensure prompt and accurateposting to the correct account. Enrollmenttransactions should be sent directly to :

Aetna Small Group Service CenterAttention Enrollment DepartmentP.O. Box 91507Arlington, TX 76015-0007

Payments must be received within the grace periodin order to avoid termination for non-payment ofpremium. If your account is terminated for non-payment, you may not have an option forreinstatement.

Renewal policy cancellations require writtennotification of intent to cancel within 30 days of therenewal. Cancellations other than at renewal require60 days advance notice. If advance notice is notprovided, we will cancel the account with the nextbilling cycle and you will be liable for all premiumsbilled through that date.

After all efforts have been made to collect premiumdue on a terminated group, Aetna will report allterminated small employer groups with past due oroutstanding balances to Dun & Bradstreet CreditServices. Dun & Bradstreet (D&B) maintains theworld’s largest business database containinginformation about 64 million businesses worldwideincluding 13 million in the United States. D&B is theleading provider of business information for credit,marketing, and purchasing decisions worldwide.

Following is a description and sample of the bill youwill receive.

Billing

Things you need to know regarding our billingand collection of premium

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Billing

Billing

You will be sent a Billing Statement monthly in advance of the statement due date. Statements are standardlyprinted 15 days prior to the premium due date and reflect enrollment changes processed prior to the print date.The billing process is also designed to maintain a list of your members.

If you have any questions regarding the information shown on your statement, please contact the Aetna SmallGroup Service Center at 1-866-899-4379. This number is also printed on each monthly statement.

A Billing statement consists of the following sections. A more detailed description of each section and anexample of a statement are shown on the following pages.! Invoice Summary and Payment Stub! Current Inforce Charges! Retroactivity/other Adjustments! Benefit Snapshot

Important Remittance Information: To ensure uninterrupted claims service, the total amount due reflected onyour invoice should be mailed to Aetna by the due date. Checks should be made payable to Aetna. Your checkshould also include your customer number and invoice number. Mail the remittance portion of the invoice withyour check enclosed in the window envelope provided, ensuring that the remittance portion is properly insertedin the envelope with the remittance address showing.

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Billing

Invoice Summary and Payment Stub

Plan KeyThe Plan Key page is self-explanatory, and lists the products and planswhere your membership is enrolled, along with transaction type codesand their descriptions.

Aetna1000 Middle StreetPremium Application Unit, MB1LMiddletown, CT 06457000025 J2B2PSP 000097

Prepared Date: 04-15-03Invoice Number: C0000208Triad Number: 0249Account Number: 80002078Bill Number: 0001Coverage Period: 05/01/03 - 05/31/03

ABC COMPANYPLAN ADMINISTRATOR123 MAIN STANYTOWN, TX XXXXX

PG. 1 OF 8

SUMMARY OF ACCOUNT:Opening Balance $18,127.24Current Inforce Charges $9,463.88Retroactivity/Other / Adjustments $936.88Net Charges $10,400.76Total Payments Received Since Last Invoice $0.00AMOUNT DUE $28,528.00

Important Please Read: The total premium is due on the first day of the monthly coverage period. If notreceived by the end of the grace period, the contract may be terminated. You will be liable for the premiumfor all periods of coverage (including the grace period) unless you provide at least 30 days advance writtennotice of your intent to terminate.

Please include your invoice number and/or account number on your check. Detach at perforation andreturn the below portion with your payment to the address provided below. Thank you for your business.

Billing Questions? Contact: Arlington Plan Sponsor Servicesat 866-899-4379

Prepared Date: 04-15-03Invoice Number: C0000208Triad Number: 0249Account Number: 80002078Bill Number: 0001Coverage Period: 05/01/03 - 05/31/03

PLEASE PAY BY AMOUNT DUEMay 01, 2003 $28,528.00

AETNA, INC.P.O. BOX 7247-0221PHILADELPHIA, PA 19178-0221

SA 0249 0000000080002778 0001 C000208 00002852800

Please make checks payable to:

5

4

12

3

1 Invoice InformationPrepared Date — Dateconsolidated bill generated.Invoice Number —Unique bill identifier.Triad Number —Service center identification.Account Number — Plansponsor unique identification.Bill Package — Accountnumber assigned at plansetup.Coverage Period —The period we are billing forcoverage.

2 Customer AddressThe address designated byplan sponsor.

3 Summary of AccountOpening Balance — Priorperiod balance, in addition tocurrent charges, minus anypayments received.Current Inforce Charges —Current charges based onactive membership as ofprepared date.Retroactivity/OtherAdjustments — Charges foractivity not previously billed oradjustments to previouslybilled amounts.Net Charges — Total ofCurrent Inforce Charges plusRetroactivity/OtherAdjustments.Paid Date — The deposit date.The number of entriesdisplayed in this section isbased on the number ofpayments received since thelast bill.Payment ID — The identifierassociated to the paymentreceived. Usually a check orwire number.Total Payments ReceivedSince Last Invoice —Total of payments receivedsince last invoice.Amount Due —Amount to be remitted.

4 MessagesImportant informationregarding payment terms andagreement.Remittance Stub — To bereturned with payment.Billing Questions —Aetna service center andphone number.

5 Remittance Address —Address where paymentsshould be mailed.Please Pay By —Payment due date.Amount Due —Amount to be remitted.

15

Billing

Current Inforce Charges1 Product Type and Premium

Product and total premiumcharged per subscriber.

2 Total SubTotal amount of premium persubscriber for all products.

3 Total Current ChargesTotal amount by product andtotal current charges.

Prepared Date: 04-15-03Invoice Number: C0000208Triad Number: 0249Account Number: 80002078Bill Number: 0001Coverage Period: 05/01/03 - 05/31/03

PG. 3 OF 8

ABC Company

CURRENT INFORCE CHARGES

Ajwani, Lena 118010100 123 525.10 103 51.00 $576.10

Albanese, Lea 118010102 123 525.10 103 52.96 $578.06

Ayendy, Lisa 118010104 103 52.96 $52.96

Ayendy, Lisa 118010104 123 525.10 $525.10

Bell, Michael 118010106 123 525.10 103 52.96 $578.06

Bowler, James 118010108 123 236.10 103 52.96 $289.10

Braulio, Ramirez 118010245 123 689.70 103 76.89 $766.59

Cristopher, James 118010205 123 441.80 $441.80

Dorrett, Irving 118010203 123 689.70 103 51.00 $740.70

James, Christopher 118010205 103 51.00 $51.00

Mancini, Angelo 118010239 123 689.70 103 76.89 $766.59

Marks, Joseph 118010236 123 689.70 103 76.89 $766.59

McBean, Melissa 118010232 123 689.70 103 76.89 $766.59

Phillip, Ireland 118010204 123 441.80 103 51.00 $492.80

Robert, Janelle 118010206 123 441.80 103 51.00 $492.80

Sapienza, Julia 118010001 123 236.10 103 27.08 $263.18

Sayer, Degan 118010002 123 236.10 103 27.08 $263.18

Scott, Richard 118010005 123 236.10 103 27.08 $263.18

Silverman, Shebly 118010003 103 27.08 $27.08

Silverman, Shelby 118010003 123 236.10 $236.10

Spalding, Eliott 118010004 123 236.10 103 27.08 $263.18

Terrile, Valerie 118010006 123 236.10 103 27.08 $263.18

Total Current Charges $8,527.00 $936.88 $9,463.88

SubscriberName

SubscriberID

Medical Dental TotalSub

*Type *TypePrem Prem

*See Plan Design

1

2

3

16

Billing

Retroactivity/Other Adjustments

Prepared Date: 04-15-03Invoice Number: C0000208Triad Number: 0249Account Number: 80002078Bill Number: 0001Coverage Period: 05/01/03 - 05/31/03

PG. 5 OF 8

ABC Company

CURRENT INFORCE CHARGES

Bowler, James 118010108 N 04/01/03 1 103 52.96 $52.96

SubscriberName

SubscriberID

Medical Dental TotalSub

*Type *TypePrem Prem

*See Plan Key

EffDate

MthsImp

*Trans

Ajwani, Lena 118010100 N 04/01/03 1 103 51.00 $51.10

Albanese, Lea 118010102 N 04/01/03 1 103 52.96 $52.96

Ayendy, Lisa 118010104 N 04/01/03 1 103 52.96 $52.96

Bell, Michael 118010106 N 04/01/03 1 103 52.96 $52.96

Braulio, Ramirez 118010245 N 04/01/03 1 103 76.89 $76.89

James, Christopher 118010205 N 04/01/03 1 103 51.00 $51.00

Dorrett, Irving 118010203 N 04/01/03 1 103 51.00 $51.00

Mancini, Angelo 118010239 N 04/01/03 1 103 76.89 $76.89

Marks, Joseph 118010236 N 04/01/03 1 103 76.89 $76.89

Phillip, Ireland 118010204 N 04/01/03 1 103 51.00 $51.00

McBean, Melissa 118010232 N 04/01/03 1 103 76.89 $76.89

Robert, Janelle 118010206 N 04/01/03 1 103 51.00 $51.00

Sapienza, Julia 118010001 N 04/01/03 1 103 27.08 $27.08

Scott, Richard 118010005 N 04/01/03 1 103 27.08 $27.08

Sayer, Degan 118010002 N 04/01/03 1 103 27.08 $27.08

Silverman, Shebly 118010003 N 04/01/03 1 103 27.08 $27.08

Terrile, Valerie 118010006 N 04/01/03 1 103 27.08 $27.08

Spalding, Eliott 118010004 N 04/01/03 1 103 27.08 $27.08

Total Retroactivity Charges $936.88 $936.88

Other Adjustments Date Amount

Total Other Adjustments $0.00

Total Retroactivity/Other Adjustments $936.88

6

5

4

1 2 3

7

1 TransTransaction type.

2 Eff DateEffective date of transaction.

3 Mths ImpThe number of monthsimpacted.

4 Product Type and PremiumProduct and total premiumcharged per subscriber.

5 Total RetroactivityTotal of all subscriberretroactive charges.

6 Other AdjustmentsList of adjustments. Debit andcredit adjustments displayedseparately by date.

7 Total Other AdjustmentsNet adjustments.

17

Billing

Benefit Snapshot

Medical 123 7 $1,852.70 4 $2,100.40 3 $1,325.40 5 $3,448.50

Dental 103 6 $162.48 4 $211.84 5 $255.00 4 $307.56

Prepared Date: 04-15-03Invoice Number: C0000208Triad Number: 0249Account Number: 80002078Bill Number: 0001Coverage Period: 05/01/03 - 05/31/03

PG. 7 OF 8

ABC Company

BENEFIT SNAPSHOTProduct Plan

TypeSingle Couples Parent/

Child (ren)Families

Subs Premium Subs Premium Subs Premium Subs Premium

*See Plan Key

6541 2 3

1 ProductDisplays only products withactive enrollment.

2 Plan TypePlan types with membershipenrolled. (See Plan Key forreference.)

3 Singles (Subscriber Only)Subs — Number of SingleSubscribers enrolled in theplan.Premium — Total amount ofpremium for Single Subscribersenrolled in the plan.

4 Couples(Subscriber + Spouse)Subs — Number of Couplesenrolled in the plan.Premium — Total amount ofpremium for Couples enrolledin the plan.

5 Parent/Child(ren)(Subscriber + 1 orMore Children)Subs — Number of Parent/Child(ren) enrolled in the plan.Premium — Total amount ofpremium for Parent/Child(ren)enrolled in the plan.

6 Families(Subscriber + Spouse + 1 orMore Children)Subs — Number of Familiesenrolled in the plan.Premium — Total amount ofpremium for Families enrolledin the plan.

Some plans in this sample are not available to allgroups in all markets.

Bills shown are for sample purposes only and do not reflect actual billing details or amounts.

18

With the power of Aetna’s technology, you and youremployees can find participating providers, researchhealth conditions, and discover the many benefitsavailable to our members. Through Aetna’s website(www.aetna.com) members have access to healthinformation resources and services designed to helpthem better manage their health care.

Aetna Navigator — The Powerto Manage Your Health CareAetna Navigator provides a single location for thehealth and medical issues that matter most to youremployees. In one easy-to-use website, memberscan perform a variety of self-service functions andtake advantage of a vast amount of healthinformation from Aetna InteliHealthSM, one of themost trusted and comprehensive health sitesavailable today, offered in association with HarvardMedical School and the University of PennsylvaniaSchool of Dental Medicine.

Log on to www.aetna.com, click on the Navigatorbutton, and check out some of Aetna Navigator’sdistinct features:! Online member service functions that allow

members to order ID cards and send e-mailinquiries to Member Services.

! Interactive “Cool Tools,” including a medicaldictionary, allergy and asthma quizzes, apregnancy due-date calculator and a heart andbreath odometer.

! A preventive care planner that includesrecommendations for screenings andimmunizations.

We will continue to add new features to AetnaNavigator, so log on often to see what’s new.

Technology Solutions

DocFind®

Finding a doctor has never been easier withDocFind, our online provider directory. Memberscan search for physicians, dentists, hospitals,pharmacies and eyewear providers. DocFind alsoallows members to search by zip code, miles willingto travel, city and state, or county and state. Narrowthe search by specialty, hospital affiliation and/orlanguages spoken — all with a few clicks of amouse. When members find the provider they want,we can also help them get there with a map anddriving directions from Maps On Us®. Best of all,DocFind is updated regularly and is available 24hours a day, 7 days a week.

Aetna InteliHealthOur award-winning health information site(www.intelihealth.com) is a premier provider ofonline consumer-based health, wellness anddisease-specific information. In addition, memberscan search a drug database and register forcondition-specific e-mails.

Aetna assumes no responsibility for any circumstances arising out of the use, misuse, interpretation or application of any information supplied byAetna InteliHealthSM. Information supplied by Aetna InteliHealth is for informational purposes only, is not medical advice and is not intended to bea substitute for proper medical care provided by a physician. Informed Health® Line nurses cannot diagnose, prescribe or give medical advice.Specific questions should be addressed to your doctor. Alternative health care programs, Vision One®

and the fitness program are rate-accessprograms and may be in addition to any plan benefits. Program providers are solely responsible for the products and services provided thereunder.Aetna does not endorse any vendor, product or service associated with these programs. Discounts offered hereunder are not insurance.Some benefits are subject to limitations or visit maximums. Members or Providers may be required to precertify, or obtain prior approval of coveragefor certain services such as nonemergency inpatient hospital care. Depending on the plan selected, new prescription drugs not yet reviewed by ourmedication review committee are either available at the highest copay under plans with an open formulary, or excluded from coverage unless amedical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescriptiondrugs and drugs, except for insulin and covered diabetic supplies, in the Limitations and Exclusions section of the plan documents (received afterenrollment) are not covered, and medical exceptions are not available for them.

19

Special Programs

Our special programs* offer a wealth of featuresthat complement our standard medical and dentalcoverage — including educational materials gearedtoward employees’ special health needs. Read on todiscover the many ways we can help you and youremployees stay healthy.

National Medical Excellence Program — whenAetna members face difficult or life-threateningsituations, such as solid organ or tissue transplants,Aetna’s National Medical Excellence (NME)program coordinates care and provides access tocovered treatment for transplants and transplantrelated services through the Institutes ofExcellence™ network. NME also coordinatesspecialized treatment needed by members withcertain rare or complicated conditions and assistsmembers who are admitted to a hospital foremergency medical care when they are travelingtemporarily outside of the United States. Servicesunder this program must be preauthorized. A listingof the Institutes of Excellence facilities can be foundin DocFind (www.aetna.com).

Cancer Screening Programs — remind age-eligible HMO and POS members to scheduleperiodic cancer screenings. Reminders are forbreast and cervical cancer screenings, as well ascolorectal cancer screenings.

Informed Health® Line — members can get theanswers to health questions anytime … day ornight. The 24-hour, toll-free Informed Health Line isa team of registered nurses who can provideinformation on a variety of health issues. InformedHealth Line nurses can only provide basic medicalinformation; they cannot diagnose, prescribe or givemedical advice. Specific questions should beaddressed by a doctor.

Healthy Outlook Program® — case management,disease-specific education and resources formembers with chronic illnesses such as low backpain, asthma, diabetes, congestive heart failure andcoronary artery disease.

Educational Programs — our educationalprograms help you follow a sensible nutrition planand become more physically active. Members areprovided with educational materials that, inconjunction with care and advice from a physician,promote a healthy lifestyle and good health.

* Availability varies by plan. Talk with your Aetna representative for details.

20

Discount Programs

Discount ProgramsAetna members, under our Vision One®, fitness andalternative health care programs, may accessdiscounted rates from certain providers for productsand services available to the general public.Products and services available under theseprograms are not covered benefits under your planbut are in addition to plan benefits. As such,program features are not guaranteed under yourhealth plan contract and could be discontinued atany time. We do not endorse any vendor, product orservice associated with these programs. Programproviders are solely responsible for the productsand services you receive.

Vision One Program** — special memberdiscounts of up to 50 percent on eye care productsand services at participating optical centers.Members also receive up to 15 percent savings onLASIK vision correction and contact lensreplacement services through our Contacts Direct™Program.

Fitness Program — members can enjoy specialmembership rates at participating health clubs anddiscounts on certain home exercise equipment.Plus, members may even try out the facility beforejoining.

Alternative Health Care Programs — reducedrates on alternative therapies for members,including visits to acupuncturists, chiropractors,massage therapists and nutritional counselors. Plus,you can also save on over-the-counter vitamins andnutritional supplements through the VitaminAdvantage™ Program.

Check out our website at www.aetna.com today.With just a few clicks, you can receive additionalproduct information, download brochures and more.

** Vision One is a registered trademark of Cole Managed Vision.

21

Supplies

Supply RequestsPlease use the following materials to administeryour plan with your employees. We also encourageyou to use our website: www.aetna.com. There is asection dedicated to employers. There you can findinformation about:! Our Products! Health Initiatives! Employer News! Features

You can make copies of the following materialsand distribute as needed to your employees.

If you should need additional enrollmentinformation, enrollment/change forms, healthquestionnaires and/or provider directories, contactyour broker or contact Aetna by calling ustoll free at 1-866-899-4379, prompt 1 orby email at SWASGSupply@aetna.com.

22

GR-67834-7 (3-03) TX - SGB R-POD

E. Declination/Waiver of Coverage - To be completed if medical and/or dental coverage is declined or refused by an eligible employee and/or their eligible family members.

Date (Month / Day / Year)

X

1. Medical Coverage Declined for:Myself Spouse Dependents

2. Dental Coverage Declined for:

Myself Spouse Dependents

Texas Small Group BusinessEmployee Enrollment/Change Form Member Aetna ID Number (if available)

Covered by spouse's group coverage - Carrier Name and ID Number:Enrolled in other Insurance Carrier Plans - Carrier Name and ID Number:Spouse covered by employer's group medical coverageMedicare Covered by TRICARE or CHAMPVA Other (Explain):

Spouse covered by employer's group dental coverage

INSTRUCTIONS: You, the employee, must complete this enrollment form in full or it will be returned to you resulting in a delay inprocessing. You are solely responsible for its accuracy and completeness. If waiving coverage, please complete Sections B and E.

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

Effective Date

Employer Name

Date of Hire

Aetna Primary CareTM Plan HMO - Plan

Aetna ChoiceTM Plan PPO - Plan

Remove Spouse/DependentChild

Employee Termination

Cancel CoverageOther

Add Spouse/Dependent Child

Change of Coverage

Name Change

Late Enrollment

Rehire/Reinstatement Other

New Hire

New Group Enrollment

COBRA/State Continuation for:Employee Dependent

Length of Continuation:18 36 Other

Original Qualifying Event Date

Reason

C. Individuals Covered - List individuals for whom you are enrolling or adding/changing/removing coverage. Attach additional sheets if necessary.Name (Last, First, M.I.) Social Security No. Birthdate

MM / DD / YYYY Heig

ht (

ft., i

n.) Primary Office

ID Number(If applicable)

/ /

/ /

/ /

/ /

Curr

ent P

atie

nt

Yes

Curr

ent P

atie

nt

Yes

Sex

M/F Wei

ght

(lbs.

) Dental OfficeID Number

(If applicable)

(A)d

d(C

)han

ge(R

)em

ove

CoverageElection

MedicalDental

MedicalDental

Oth

er H

ealth

Cove

rage

Oth

er D

enta

lCo

vera

ge

Stud

ent A

ge19

or O

lder

(for L

ife/A

D&D

only

)Yes Yes Yes

Inca

paci

tate

d

YesN/A

N/AMedicalDental

MedicalDental

Subscriber Primary Language (other than English)Primer Idioma del suscriptor (que no sea el Ingles)What is your primary Language

¿Cuál es su primer idioma?

Subscriber Disability

Do you have a disability which affects your ability to communicate or read?

If Yes, please indicate the nature of your disability.Yes No

Option 1

Option 2: DMO or PDN

Option 3: DMO or PDN

N/A

N/A

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

Beneficiary Designation - Full Name (First, Middle, Last)

Beneficiary Social Security No. Relationship to Employee

1. Medical - Check one. 3. Life and Disability2. Dental - Check one.

Optional Dependent LifeLife and Disability Packaged Plan

Basic Life / AD&D UltraTM

B. Employee Information - Must be completed by the employee.Last Name, First Name, M.I.Social Security Number

Home Address

Work Address

Apt. No. City, State ZIP Code

Home Telephone

City, State ZIP Code Work Telephone

Job Title

Salary (required) No. of Hours Worked Per Week Check One Marital StatusHourly Weekly Monthly Part-time Full-time Married Single

No. of Dependents Including Spouse$

D. Race/Ethnicity - Optional

1.

Employee

2.Spouse

3.White - 01Hispanic or Latino - 03

African American or Black - 02Asian - 04 Other - 05

White - 01Hispanic or Latino - 03

African American or Black - 02Asian - 04 Other - 05

White - 01Hispanic or Latino - 03

African American or Black - 02Asian - 04 Other - 05

White - 01Hispanic or Latino - 03

African American or Black - 02Asian - 04 Other - 054.

Child

Child

(This information is designed for the purpose of data collection and will not be used for determining eligibility, rating or claim payment.)

I acknowledge I have been given the right to apply for this coverage, however, I am electing not to enroll. By declining this groupcoverage I acknowledge that myself and/or my dependents may have to wait until the plan's next anniversary date to be enrolled forgroup coverage. Pre-existing conditions, when enrolled in other than an HMO plan, may not be covered for twelve months.

Aetna DirectTM Plan

Reason for Declining Coverage (If applicable, please attach front/back of your health coverage ID card.):

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

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

Employee

1.

2.

3.

4.

Child

Child

Spouse

On behalf of myself and the dependents listed on the reverse side, 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 Primary Care Plan HMO: Aetna Health Inc.· Aetna Dental DMO: Aetna Dental Inc.· Life, disability, dental and all other health 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 theeligible employee and employer applications have been accepted and approved by Aetna. Even if this enrollment form is approved, anymisstatements or omissions may result in future claims being denied and the policy or my coverage under the policy being rescinded orreevaluated, as of the effective date, for eligibility and rating purposes. For life and disability coverages: I understand that theeffective 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 effectivedate of insurance for any of my dependents is also subject to the dependent health condition requirements of the benefit plan. Further, Iunderstand that any insurance subject to evidence of good health or medical information will not become effective until Aetna gives itswritten consent.

3. I understand and agree that this Enrollment form may be transmitted to Aetna or its agent by my employer or its agent. I authorize anyphysician, other healthcare professional, hospital or any other healthcare organization (“Providers”) to give to Aetna or its agentinformation concerning the medical history, services or treatment provided to anyone listed on this Enrollment form, including thoseinvolving mental health and substance abuse. I further authorize Aetna to use such information and to disclose such information toaffiliates, providers, payors, other insurers, third party administrators, vendors, consultants and governmental authorities with jurisdictionwhen necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related activities. I havediscussed the terms of this authorization with my spouse and competent adult dependents, and I have obtained their consent to thoseterms. I understand that this authorization is provided under state law and that it is not an “authorization” within the meaning of the federalHealth Insurance Portability and Accountability Act. This authorization will remain valid for the term of the coverage and for so longthereafter as allowed by law. I understand that I am entitled to receive a copy of this authorization upon request and that a photocopy isas 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 benefitscomparison, 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 independentcontractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability ofany particular provider cannot be guaranteed and provider network composition is subject to change. Notice of the change shall beprovided 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 forreferred benefits, and that, in order to be covered, services must be performed either by a participating primary care physician, primarycare dentist or by the participating specialist, hospital, pharmacy, dentist, or other provider as authorized by a referral from a participatingprimary care physician.

7. I understand and agree that, as described in the plan documents and when enrolled for medical coverage in other than an HMO plan,any pre-existing conditions for my spouse, dependents or myself may not be covered for 12 months.

Conditions of Enrollment

8. I authorize deductions from my earnings for any contributions required for coverage, and I agree to make any necessarypayments as required for coverage.

Authorization

Misrepresentation9. It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.

In addition, an insurer may deny insurance benefits if false information materially related to the claim was provided by theapplicant.

I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions of Enrollment,Authorization and Misrepresentation on this Texas Small Group Business Employee Enrollment/Change Form. I understand that, inthe event I fail to sign this form within 31 days after the above transaction request or for any reason Aetna does not receive notice ofthe 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, usually 30 hours per week, for this employer at theregular place of business.

If you have questions concerning the benefits and services that are provided by or excluded under this Agreement, please contact aMember Services representative at 1-800-323-9930 before signing this form.Employee Signature Date (Mo/Day/ Yr)

XEmployee E-mail Address(optional)

Spouse Signature

X

G. Other Insurance

If you have checked "Yes" to Other Dental Coverage (Section C), provide name and policy number of insurance carrier, HMO, or other source, a copy of the insurance card and start date of the coverage.

If you have checked "Yes" to Other Health Coverage (Section C), provide name and policy number of insurance carrier, HMO, or other source, a copy of the insurance card and start date of the coverage.

Is your Spouse Employed? If "Yes," provide name and address of spouse's employer.Yes No

F. Dependent InformationDoes any dependent listed in Section C live at another address? If Yes, who and what address? If any dependent's last name differs from yours, explain the circumstances.

Yes No

Yes NoPROOF OF PRIOR COVERAGE - IMPORTANT (Required)Does anyone enrolling on this enrollment form have prior coverage?If you answered “yes”, provide applicant names, start and end dates of priorcoverage.

Proof of coverage must accompany this enrollment form for pre-existing conditioncredit if enrolling in other than an HMO plan.

Acceptable forms of proof are:1. Certificate of Creditable Coverage from prior carrier, or2. Copy of ID card or most recent payroll stub showing medical coverage

deduction, or3. Copy of most recent medical premium bill from prior carrier.

Failure to provide Proof of Prior Coverage may subject you or a familymember to the full pre-existing conditions limitation with no credit for priorcoverage if enrolling in other than an HMO plan. You may request aCertificate of Creditable Coverage from your prior carrier.

Selecting a physician and other health care providers for you and your family is important. DocFind, our online provider directory available 24 hours a day, 7 days a week, makes your decision process easier.

DocFind is Aetna’s premier online provider search tool. Up-to-date listings of participating physicians, dentists, other medical professionals and facilities are available at your fingertips. With our easy-to-use format, you can search for a provider online by name, specialty, genderand/or hospital affiliation.

How Do I Use DocFind?You can use DocFind anywhere you have Internet access. A step-by-step overview of how to use DocFind is on the back of this flyer. If you have questions while searching for a provider, simply click on the “Contact DocFind” link located at the top of any DocFind page to send us a commentor question. Once you become a member, you can also callMember Services with questions about your benefits by using the toll-free number on your member ID card.

What Does DocFind Enable Me to Do?• Choose from two search options. Search for a provider

by using criteria such as specialty, gender and/or hospitalaffiliation, or search using just the provider’s name. Moreinformation about search options is available on the back of this page.

• Make the informed choice. DocFind gives you easy access to information about providers that is not available in paper directories. This includes information about which plans the provider accepts, medical school attended,board certification status, and gender, as well as informationabout the provider’s offices, such as handicapped access,office hours, etc. Other features include maps, drivingdirections and listings, where applicable, of a provider’s other office locations.

• Get up-to-date information. DocFind is updated three times per week, giving you access to the latest available information.

• Enjoy personalized search features via Aetna Navigator.Don’t forget to visit the Aetna Navigator™ online memberservices website. By registering, you’ll get a personalizedversion of DocFind, which pre-fills your plan name and zip code, making your search even easier. And while you are there, check on the status of a claim, request ID cards,contact Aetna Member Services and more!

• Review a list of transplant facilities in our Institutes of Excellence™ network.

• DocFind en Espanol. DocFind now offers a Spanish versionof the website. From the home page of DocFind, a user maysimply click on the “Version en espanol” button at the topof the page to switch to the Spanish version.

Locate providers using the criteria best suited to your needs!

See back of this flyer for instructions.

11.03.300.1 (5/03)C

DocFind® Provider DirectoryFacts at a Glance

Step-by-Step InstructionsTo access DocFind, simply log onto www.aetna.com. If you are not yet a member, go directly to DocFind from the Aetna home page. If you are already a member, go to Aetna Navigator to access DocFind.

Considering enrolling in an Aetna plan? Looking to change your PCP? Need to locate a specialist?

DocFind’s “Standard Search” can help!

1. Enter the geographic information for the area where you wish to find a participating provider.

2. Select the type of provider you wish to find, such as Primary Care Physician (PCP), Specialist, Dentist, Medical Hospital or Pharmacy.

3. Select a plan.

4. If you choose, narrow your search by specialty, gender,languages spoken, hospital affiliation and/or name. Or,request a list of all providers who match your geographic and plan requirements.

5. That’s it! You will be presented with a list of providers who match your criteria. You can obtain additionalinformation about each provider by clicking on the“Provider Detail” link.

Know the name of the provider you’re looking for?

“Search By Name” is your direct route!

1. Enter the geographic information for the area where you wish to find a participating provider.

2. Input the name of the individual provider you wish to find.

3. Select the type of provider you would like to find — either Medical or Dental — and hit “Continue.”

4. It’s that easy! You will be presented with a list of theproviders who match your requirements. You can obtainadditional detail about a particular provider by clicking on the “Provider Detail” link.

Need a paper directory?If you are already an Aetna member, please call the toll-freeMember Services number on your ID card.

If you are considering the HMO, Aetna Open Access® HMO,Quality Point-of-Service® (QPOS®), Aetna Choice™ POS orUSAccess® plan, please call 1-800-323-9930.

If you are considering the Elect Choice®, Aetna Open AccessElect Choice, Managed Choice®, Aetna Open Access ManagedChoice or Open Choice® plan, please contact your employer or plan sponsor.

Log on to www.aetna.com today for easy access to up-to-date participating provider information!

www.aetna.comThe availability of a plan or program may vary by geographic service area. Participating physicians, hospitals and other health care providers are independent contractors and areneither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the changeshall be provided in accordance with applicable state law. While this material is believed to be accurate as of the print date, it is subject to change. “Aetna” is the brand name usedfor products and services provided by one or more of the Aetna group of subsidiary companies. Those companies include: Aetna Health Inc., Aetna Health of California Inc., AetnaHealth of the Carolinas Inc., Aetna Health of Illinois Inc., Aetna Health of Washington Inc., Corporate Health Insurance Company, Aetna Health Insurance Company of New York,Aetna Health Insurance Company of Connecticut and/or Aetna Life Insurance Company.

11.03.300.1 (5/03) Available in Spanish. Disponible en Español. ©2003 Aetna Inc.C

Aetna’s Benefits and Health Information Website

As an Aetna member, Aetna Navigator is your online resourcefor personalized benefits and health information. Aetnamembers can take full advantage of our interactive website to complete a variety of self-service transactions online.

Need instant eligibility information or a replacement member ID card?

Want to change a primary care physician and/or dentist?

Need to check the status of a claim?

You can do it all online — 24 hours a day, 7 days a week —from wherever you have Internet access.

Aetna Navigator helps you make the most of yourbenefits plan. You can also: • Review who is covered on your plan.

• Check your Flexible Spending Account (FSA)* status.

• Research the price of a drug and learn if there are less-costly alternatives.

• Receive personalized health and benefits messages.

• Contact Aetna Member Services.

In addition, you’ll have access to credible health information on the Web.

For further details about Aetna Navigator, including manymore personalized features you can access when you register,please refer to the back of this fact sheet. If you need moreinformation, contact your employer.

*If included in your plan.

Don’t delay! Take a tour of AetnaNavigator today at www.aetna.com.

Aetna Members, Register Today!

If you are currently a member of an Aetna medical,dental or FSA plan, you may register today!• Go to www.aetna.com and select Aetna Navigator

in the “Quick Tools” drop-down box.

• Click on the “Register” link.

• Complete the requested information to verify that you are an Aetna member.

• Select a user name, password and security phrase.

Once your registration is complete, your user name andpassword will give you access to Aetna Navigator. Your claims data and Explanation of Benefits will be available ten days after you register. You will receive a confirmation letter via the U.S. Postal Service at the address we have on file. You can find help with questions about registration,security and software by clicking on “About Registration” at the top of the online registration form. Personal registrationassistance is available toll free, Monday through Friday, from 7 a.m. to 9 p.m. Eastern Time at 1-800-225-3375.

11.03.312.1 (8/03)

Aetna Navigator™

Overview for Members

continued on back

A

Key Features*

Review Your Plan and Benefits Information• Who is covered, primary care physician (PCP) or primary care

dentist (PCD) selections, claims status for medical, dental andpharmacy, and Explanation of Benefits (EOB) statements.

• Aetna’s pharmacy information, including the MedicationFormulary Guide, directories of participating pharmacies,Aetna’s mail-order drug program, and the Price-A-DrugSM tool.

• Flexible Spending Account (FSA) status, account balance(s),payment details and tools for understanding and managinghealth care and dependent care spending accounts.

Perform Transactions• View and print instant medical/dental eligibility information

and request replacement member ID cards.

• Obtain Aetna Member Services contact information,including phone numbers and mailing addresses.

• Send a secure message to Aetna Member Services (alsoavailable in Spanish). From the claims detail page, send amessage about a specific claim with important informationabout the claim prefilled in the message.

• Search our DocFind® online provider directory, in English or Spanish — for information on participatinghospitals, physicians, dentists, specialists, pharmacies and other providers, including maps and directions, office locations, physician education and hospital affiliations, and languages spoken other than English.

• Change PCP and/or PCD selections.

• Print out Aetna standard forms.

*Some of these features may vary by plan.

Access Sources of Health Information• Aetna InteliHealthSM — Our award-winning consumer

website, for credible health, dental and wellness informationprovided by Harvard Medical School and the University ofPennsylvania School of Dental Medicine.

• Healthwise® Knowledgebase — A user-friendly onlineinformation tool that lets you research your own issues and preferences for health information.

• Interactive and Streaming Videos — Health topics such as asthma and healthy heart.

Utilize Tools to Manage Health Care• Price-A-Drug — Helps you estimate the cost of prescriptions

before you buy.

• Aetna Navigator™ Hospital Comparison Tool — Compareshospital outcome information about medical care providedby hospitals in your area, based on criteria important to you.

• Evaluate Your Health Care Provider — Take a survey on an Aetna participating physician or other provider whoprovided medical care to you or your dependents within the last 12 months.

View Personalized Health Topics and Messages• Personalize the health topics on your home page.

• Receive online preventive health care reminders aboutscreenings and other health measures depending on the age and gender of you and each covered dependent.

• Request e-mail alerts when new information, such aspreventive health care reminders, EOB statements or FSA payments, is available for you to view on your secure Aetna Navigator home page.

www.aetna.comIf you need this material translated into another language, please call Member Services at 1-800-323-9930.Si usted necesita este material en otro lenguaje, por favor llame a Servicios al Miembro al 1-800-323-9930.

This material is for informational purposes only. The availability of Aetna Navigator’s key features may vary by plan. With the exception of Aetna Rx Home Delivery, all participatingphysicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary ofAetna 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 inaccordance with applicable state law. Aetna assumes no responsibility for any circumstances arising out of the use, misuse, interpretation or application of any information suppliedby Aetna InteliHealth or Healthwise Knowledgebase. Information supplied by Aetna InteliHealth or Healthwise Knowledgebase is for informational purposes only, is not medical adviceand is not intended to be a substitute for proper medical care provided by a physician. While this material is believed to be accurate as of the print date, it is subject to change.“Aetna” is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. Those companies include: Aetna Health Inc., Aetna Health of California Inc., Aetna Health of the Carolinas Inc., Aetna Health of Illinois Inc., Aetna Health of Washington Inc. and/or Aetna Life Insurance Company.

For the Commonwealth of Virginia, one or more of the following policy numbers may apply: GR-67603-5; GR-9; GR-29; GR-27; GR-7; GR-89296; GR-89297; GR-700-W; GR-70-W; GR-96124; GR-96125; HMO/VA COC-1 07/99; CHI/VA SBQNET-1 01/00; HMO/VA SELFREF(10/00); HMO/VA AMEND-URGENT-1 07/01; HMO/VA SUPSVSEND-4 01/02; HMO/VA GA-1 01/02; CHI/VA GP-1 04/02; HMO/VA COC-AMEND-3 07/02; HMO/VA NAMEAMEND-1 05/02; HMO/VA Amendment to GA ELR-1 05/02; HMO/VA SB-1 10/02; CHI/VA INSCT-1-[A-K] (10/01); CHI/VA SBQPOS-1 10/01.

11.03.312.1 (8/03) Available in Spanish. Disponible en Español. ©2003 Aetna Inc.A

00.03.301.1-TX (8/03)

Vision One® Discount ProgramEye Care Savings with No Referrals and No Claim Forms

Aetna medical and dental members, through the Vision Onediscount program, may access discounted rates from certainproviders for products and services available to the generalpublic. Products and services available under this program arenot covered benefits under your plan but are in addition toplan benefits. As such, program features are not guaranteedunder your plan contract and could be discontinued at anytime. We do not endorse any vendor, product or serviceassociated with this program. Program providers are solelyresponsible for the products and services you receive.

As anyone who wears contact lenses or eyeglasses can tellyou, having less-than-perfect vision can be costly. The VisionOne discount program* helps you and your family save onmany eye care products, including eyeglasses, contact lenses,nonprescription sunglasses, contact lens solutions and other eyecare accessories. Plus, you can receive up to a 25% discount onLASIK surgery (the laser vision correction procedure).

The Vision One discount program is available to Aetna membersthrough Cole Managed Vision at no additional cost.

Here’s How It Works

1. Find the location nearest you.It’s simple. Just log onto www.aetna.com, click on DocFindand select Vision One. Or call Vision One Customer Service(1-800-793-8616) to find a participating provider near you.Choose from a wide selection of optical centers nationwide,including Sears, JCPenney, Target, participating Pearle Visioncenters and others, as well as through selected independentoptometrist and ophthalmologist offices.

2. Schedule an eye exam.Well-eye exams are an important part of a healthylifestyle. If your benefits plan covers eye exams, consult your provider directory or log onto www.aetna.com, andclick on our DocFind® online provider directory for a list of participating optometrists and ophthalmologists. Your out-of-pocket expenses could be lower if you follow yourplan requirements. Covered eye exams are available frommost providers at Vision One locations. Check your plandocuments for additional coverage and other important details.

If your benefits plan does not cover eye exams, you can receive an exam at a discounted rate with Vision One.Schedule an appointment with a Vision One provider and pay the discounted exam rate (see schedule on next page for details) for eyeglasses or contact lenses. Most Vision One locations have doctors of optometrypracticing on the premises or at a location nearby.

3. Save on eyewear.Choose from hundreds of fashionable frames and thelatest in lens technology. Simply show your Aetna ID card,and any applicable services or products you receive will bediscounted right at the point of purchase. There are no claimforms to complete and no waiting for reimbursement.

SPECIAL SAVINGS ON LASIK

You and each member of your family can also receive up to a 25% discount off the provider’s usual fee for LASIKsurgery through the NuVision LASIK Network.** Thisdiscounted price includes patient education, an initialscreening, the LASIK procedure and follow-up care. Best of all, the initial consultation is always free, even if you elect not to proceed with surgery.

Three Simple Steps

1. Schedule a free evaluation with a participating LASIK surgeon in your area. Our LASIK information specialists are ready to answer your questions, review the doctorsavailable in your area with you and schedule aconsultation with the doctor you choose. So call LASIKCustomer Service toll free at 1-800-422-6600 today.

2. At your initial visit, present your Aetna ID card and indicatethat you are part of the Vision One discount program.

3. Schedule a surgery date with your provider, and call LASIK Customer Service (1-800-422-6600) to make payment arrangements. You can pay for LASIKsurgery with a check or credit card. Qualifying patientscan request a low monthly payment plan, with terms ranging from 12 to 60 months or a 6-monthsame-as-cash program.

*Vision One is a discount-only program. It is in addition to any vision care plan benefits you may have through your health benefits plan.

**LASIK surgery discounts are offered by Cole Managed Vision. Providers are independent surgeons and are not agents or representatives of Cole Managed Vision, Aetna Health Inc. and/or their affiliates.

www.aetna.comThis material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of the program and doesnot constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. The availability of a plan or program mayvary by geographic service area. The Vision One discount program is a rate-access program and may be in addition to any plan benefits. Program providers are solelyresponsible for the products and services provided thereunder. Aetna does not endorse any vendor, product or service associated with this program. Discounts offeredhereunder are not insurance. Vision One and the Vision One discount program are registered trademarks of Cole Managed Vision. NuVision is a registered trademark ofNuVision, Inc. “Aetna” is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, which may include: AetnaHealth Inc., Aetna Life Insurance Company and/or Aetna Dental Inc. While this material is believed to be accurate as of the print date, it is subject to change.

00.03.301.1-TX (8/03) ©2003 Aetna Inc.

Discounted prices on eye care services and eyewearproducts through Vision One participating providers are listed below. These prices are subject to change.

PRODUCT OR SERVICE MEMBER COST

Eye Exams for Plans That Cover Eye Exams

Refer to your health benefits plan documents for coverage details.

Eye Exams for Plans That Do Not Cover Eye Exams

For eyeglasses $38For standard contact lenses $78For specialty contact lenses

(i.e., Toric, Bifocal, Gas Permeable) $10 off standard fee

Lenses per Pair (uncoated plastic)

Single Vision $30Bifocal $49Trifocal $59Standard Progressive (no-line bifocal) $99

Eyeglass Frames (retail prices)

Up to $60.99 $24$61 to $80.99 $34$81 to $100.99 $44$101 and up 40% off retail

Lens Options per Pair (add to lens price above)

Polycarbonate (includes UV coating and scratch-resistant coating) $30

Scratch-resistant coating $12Ultraviolet (UV) coating $12Solid or gradient tint $ 8Glass $15Photochromic glass $34Anti-reflective coating $35

Contact Lenses

Visit any participating Vision One location and receive a 20% discount off retail prices (10% discount on disposables).

Mail Order Contact Lens Replacement Program

Call 1-800-391-LENS (5367) to order replacement contact lenses for additional convenience.

Additional Vision-related Items

Visit any participating Vision One location and receive a 20% discount off retail prices.

LASIK Procedure

You and your family members can receive up to a 25% discount off the surgeon’s fee through the NuVision® LASIK network.

Mail Order Contact Lens Replacement

After you purchase your first pair of contact lenses at a Vision One or other eye care location, you can receiveadditional pairs in two ways:

1. Have your prescription refilled at a participating Vision One location.

2. Order replacement contact lenses through the mail using the Vision One Contact Lens Replacement program. You’ll receive the same brand-name lenses your doctor prescribed, but generally at a lower cost. Call 1-800-391-LENS (5367) for more information.

Questions?

Vision One Exam and Eyewear 1-800-793-8616Weekdays 9 a.m. – 9 p.m. Saturdays 9 a.m. – 5 p.m.Eastern Time

LASIK Customer Service 1-800-422-6600Weekdays 8 a.m. – 9 p.m. Saturdays 9 a.m. – 6 p.m. Eastern Time

Mail Order Contact Lens Replacement 1-800-391-LENS (5367)

Alternative Health Care ProgramsAn Alternative Approach to Maintaining Good Health

Aetna members, under the Alternative Health Care Programs,may access discounted rates from certain providers for productsand services available to the general public. Products andservices available under these programs are not coveredbenefits under your plan but are in addition to plan benefits.As such, program features are not guaranteed under yourhealth plan contract and could be discontinued at any time.We do not endorse any vendor, product or service associatedwith these programs. Program providers are solely responsiblefor the products and services you receive.

Our Alternative Health Care Programs help you save on a varietyof alternative approaches to preventive care and the maintenanceof good health — from chiropractic services to vitamins,nutritional supplements and other health-related products.

Take a look at what these programs have to offer:

Natural Alternatives Through this special discount program, you can take advantageof many alternative health-related services from chiropractors,acupuncturists, massage therapists and nutritional counselors —all at reduced rates.

This program is easy to use. To find a participating providernear you, check out our website at www.aetna.com, or callthe Member Services number on your ID card. A schedule ofNatural Alternatives services and fees will be sent out with theprovider list. You can use any participating Natural Alternativesprovider at any time, subject to provider ability, without referralor prior authorization from Aetna.

Here’s How to Take Advantage of the Program:

1. Confirm that the service you want is available throughNatural Alternatives.

2. Call the provider of choice directly to schedulean appointment.

3. Pay the discounted fee directly to the provider when the service is received. Because this is a discount program,there is no need to file claims.

Vitamin Advantage™ ProgramThrough the Vitamin Advantage program, you can saveon over-the-counter vitamins and nutritional supplementspurchased through participating vendors.

Natural ProductsYou can also save on many health-related products, includingaromatherapy, foot care and natural body care products.

For health-related products available through the VitaminAdvantage and Natural Products programs, you can placeorders in four ways: mail, telephone, fax or through ourwebsite, www.aetna.com.

Important InformationFor up-to-date, detailed information about our AlternativeHealth Care Programs, you can always call Member Servicesat the number on your ID card. You can also visit www.aetna.com,where you’ll find a list of participating providers, vendors and thelatest additions to our product list. Visit our website often …these programs are growing.

www.aetna.comIf you need this material translated into another language, please call Member Services at 1-800-323-9930.Si usted necesita este material en otro lenguaje, por favor llame a Servicios al Miembro al 1-800-323-9930.

The Alternative Health Care Programs are rate-access programs and may be in addition to any plan benefits. Program providers are solely responsible for the products and servicesprovided thereunder. Aetna does not endorse any vendor, product or service associated with these programs. Discounts offered hereunder are not insurance. Program providers areindependent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna does not recommend the self-management of health problems, nordo we promote any particular form of medical treatment. You should consult your health care provider for the advice and care appropriate for your specific medical needs. This materialis for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does notconstitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. The availability of a plan or program may vary bygeographic service area. “Aetna” is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. Those companies include:Aetna Health Inc. and/or Aetna Life Insurance Company.

28.03.301.1-TX (8/03) ©2003 Aetna Inc.

Aetna medical and dental members, under the FitnessProgram, may access discounted rates from certainproviders for products and services available to the general public. Products and services available under thisprogram are not covered benefits under your plan but are inaddition to plan benefits. As such, program features are not guaranteed under your plan contract and could bediscontinued at any time. We do not endorse any vendor,product or service associated with this program. Programproviders are solely responsible for the products and services you receive.

Regular exercise helps maintain your physical and mental well-being. So get ready … and get set to start exercising — and saving — today. The Fitness Program from Aetna isavailable to you as an Aetna member to help you get started.

With the Fitness Program, Offered in Conjunction with GlobalFit™, You Can: • Access and receive discounts on membership rates at

independent health clubs that have contracted with GlobalFit as part of their national network.

• Receive discounts on certain home exercise equipment.

Consider Even More Advantages of the Fitness Program:

• Find clubs close to where you live or work.

• Free guest pass* to sample a club before joining.

• Month-to-month membership, with no long-term contracts.

• Convenient, monthly payment options (checking or savingsaccount, or major credit card).

• Transfer, freeze or cancel your membership conveniently.

• Share the club membership savings with your familymembers who are covered dependents.

• Guest privileges at GlobalFit™ clubs for when you travel.

Two Easy Steps to Join1. Find a club. Visit www.globalfit.com/fitness for an updated

listing of clubs in your area. Or, call 1-800-298-7800 to speak to a GlobalFit representative who can answerquestions about club hours, locations and amenities. They’llalso send you a club directory and other program materialsto get you started.

2. Join a club. Simply enroll online at www.globalfit.com/fitnessor call GlobalFit toll free at 1-800-298-7800.**

Take charge of your health, so you canlook and feel your best. Reach for your fitnessgoals by participating in a regular fitnessroutine, with a little help from Aetna.

*Not available at all clubs. **At some clubs, program participation may only be available

to new club members.

Fitness ProgramSavings on Health Club Memberships, Exercise Equipment and More

00.03.300.1-TX (8/03) Available in Spanish. Disponible en Español. ©2003 Aetna Inc.

www.aetna.comIf you need this material translated into another language, please call Member Services at 1-800-323-9930.Si usted necesita este material en otro lenguaje, por favor llame a Servicios al Miembro al 1-800-323-9930.

This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and doesnot constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. The availability of a plan or program may vary bygeographic service area. The Fitness Program is a rate-access program and may be in addition to any plan benefits. Program providers are solely responsible for the products and servicesprovided thereunder. Aetna does not endorse any vendor, product or service associated with this program. Discounts offered hereunder are not insurance. “Aetna” is the brand name usedfor products and services provided by one or more of the Aetna group of subsidiary companies. This program is offered by: Aetna Health Inc., Aetna Life Insurance Company and/or AetnaDental Inc. While this material is believed to be accurate as of the print date, it is subject to change.

14.07.901.1-TX (2/04) ©2004 Aetna Inc.