101.28.302.1-MA (7/05)

DISCLOSURE NOTICEThis disclosure notice is provided in accordance withthe laws of the Commonwealth of Massachusetts.This disclosure notice is only a summary of certainprovisions of the plan. The Aetna** policy,agreement, or certificate of coverage should beconsulted to determine governing contractualprovisions. Members may contact Aetna at thetelephone number shown on their I.D. Card.

TERMINATION OF COVERAGEA member’s coverage may be cancelled, or its renewalrefused, only in the following circumstances.

1. Failure by the member or other responsible party tomake payments required under the contract;

2. Misrepresentation or fraud on the part of themember;

3. Commission of acts of physical or verbal abuse by themember which pose a threat to providers or othermembers of the Aetna and which are unrelated tothe physical or mental condition of the member;

4. Relocation of the member outside the service area ofAetna;

5. Non-renewal or cancellation of the group contractthrough which the member receives coverage; or

6. Failure by the member to meet the eligibilityrequirements of the contract.

CLAIM PROCEDURES/COMPLAINTS ANDAPPEALS

CLAIM PROCEDURESA claim occurs whenever a Member or the Member’sauthorized representative requests preauthorization asrequired by the plan from Aetna, a Referral as required bythe plan from a Participating Provider or requests paymentfor services or treatment received. As an Aetna Member,most claims do not require forms to be submitted.

However, if a Member receives a bill for Covered Benefits,the bill must be submitted promptly to Aetna for payment.Send the itemized bill for payment with the Member’sidentification number clearly marked to the address shownon the Member’s ID card.

Aetna will make a decision on the Member’s claim. Forurgent care claims and preservice claims, the Aetna willsend the Member written notification of thedetermination, whether adverse or not adverse.

Aetna shall make an initial Utilization Reviewdetermination regarding a proposed admission, procedureor service claim within two (2) working days of obtainingall necessary information. Necessary information shallinclude the results of any face-to-face clinical evaluation orsecond opinion that may be required. In the case of adetermination to approve a Utilization Review admission,procedure or service, Aetna shall notify the Providerrendering the service by telephone within 24 hours, andshall provide written or electronic confirmation of thetelephone notification to the Member and the Providerwithin two (2) working days thereafter.

Aetna shall make a concurrent Utilization Reviewdetermination within one (1) working day of obtaining allnecessary information. In the case of a determination toapprove a concurrent claim, Aetna shall notify the Providerrendering the service by telephone within one (1) workingday, and shall provide written or electronic confirmation tothe Member and the Provider within one (1) working daythereafter. The written or electronic notification shallinclude the number of extended days or the next reviewdate, the new total number of days or services approved,and the date of admission or initiation of services.

For other types of claims, the Member may only receivenotice if Aetna makes an adverse determination.

A Member may contact Member Services at the toll-freetelephone number on their ID card to determine the statusor outcome of Utilization Review decisions.

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* State mandates do not apply to self-funded plans. If you are unsure ifyour plan is self-funded, please contact your benefits administrator.

**Aetna is the brand name used for products and services provided by oneor more of the Aetna group of subsidiary companies.

Important Disclosure Information*MassachusettsHMO, Aetna Open Access®, Aetna Choice® POS, USAccess®, and QPOS® Members

ADVERSE DETERMINATIONSAdverse determinations are decisions made by Aetna thatresult in denial, reduction, or termination of a benefit orthe amount paid for it. It also means a decision not toprovide a benefit or service. Adverse determinations canbe made for one or more of the following reasons:

� Utilization Review. Aetna determines that the service orsupply is not Medically Necessary or the requestedservice or supply is an Experimental or InvestigationalProcedure;

� No Coverage. Aetna determines that a service orsupply is not covered by the plan. A service or supply isnot covered if it is not included in the list of CoveredBenefits;

� it is excluded from coverage; or

� an Aetna limitation has been reached; or

� Eligibility. Aetna determines that the Subscriber orSubscriber’s Covered Dependents are not eligible to becovered.

The written notice of an adverse determination shallinclude a substantive clinical justification that is consistentwith generally accepted principals of professional medicalpractice and shall, at a minimum, also provide thefollowing important information that will assist theMember in making an Appeal of the AdverseDetermination, if the Member wishes to do so:

(a) identify the specific information upon which theadverse determination was based;

(b) discuss the Member’s presenting symptoms orcondition, diagnosis and treatment interventions andthe specific reasons such medical evidence fails tomeet the relevant medical review criteria;

(c) specify any alternative treatment options covered byAetna, if any;

(d) reference and include applicable clinical practiceguidelines and review criteria; and

(e) a clear, concise and complete description of theAetna’s formal internal Appeal process and theprocedures for obtaining external review, including theprocedure to request an expedited external review.

Written notices of an Adverse Determinations will beprovided to the Member within the following time frames.Under certain circumstances, these time frames may beextended. Please see the Complaint and Appeals sectionof this Certificate for more information about Appeals.

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UTILIZATION REVIEW

Aetna Timeframe for Notification of a Utilization Review Adverse Determination

Type of Claim Aetna Response Time from Receipt of Appeal Claim

Urgent Care Claim. A claim for medical care or treatmentwhere delay could seriously jeopardize the life or health ofthe Member, the ability of the Member to regain maximumfunction; or subject the Member to severe pain that cannotbe adequately managed without the requested care ortreatment.

Proposed Admission, Procedure or Service. A claim fora benefit that requires preauthorization of the benefit inadvance of obtaining medical care.

Concurrent Care Claim Extension. A request to extend acourse of treatment previously preauthorized by Aetna.

Concurrent Care Claim Reduction or Termination.Decision to reduce or terminate a course of treatmentpreviously preauthorized by Aetna.

Post-Service Claim. A claim for a benefit that is not aproposed admission, procedure or service claim.

Telephone the Provider within 24 hours.

Send written or electronic confirmation of the telephonenotification to the Member and the Provider within oneworking day thereafter

Telephone the Provider within 24 hours.

Send written or electronic confirmation of the telephonenotification to the Member and the Provider within oneworking day thereafter.

Telephone the Provider within 24 hours.

Send written or electronic confirmation of the telephonenotification to the Member and the Provider within oneworking day thereafter. The service shall be continuedwithout liability to the Member until the Member has beennotified of the determination.

Telephone the Provider within 24 hours.

Send written or electronic confirmation of the telephonenotification to the Member and the Provider within oneworking day thereafter.The service shall be continuedwithout liability to the Member until the Member has beennotified of the determination.

Within 30 calendar days

Aetna shall give a Provider treating a Member anopportunity to seek reconsideration of a Utilization Reviewadverse determination from a clinical peer reviewer in anycase involving an initial determination or a concurrentreview determination. The reconsideration process shalloccur within one (1) working day of the receipt of therequest and shall be conducted between the Providerrendering the service and the clinical peer reviewer or a

clinical peer designated by the clinical peer reviewer if thereviewer cannot be available within one (1) working day. Ifthe reconsideration process does not reverse the UtilizationReview adverse determination, the Member, or theProvider on behalf of the Member, may pursue the AppealProcess. The reconsideration process shall not be aprerequisite to the Appeal Process or an expedited Appeal.

COMPLAINTS AND APPEALSAetna has procedures for Members to use if they aredissatisfied with a decision that Aetna has made or withthe operation of the Aetna. The procedure the Memberneeds to follow will depend on the type of issue orproblem the Member has.

� Inquiry. An Inquiry is any communication that has notbeen the subject of an adverse determination and thatrequest redress or an action, omission or policy ofAetna.

� Appeal. An Appeal is a request to Aetna to reconsidera Complaint or an adverse determination. The Appealprocedure for a Complaint or an adverse determinationhas two levels.

� Complaint. A Complaint is any Inquiry that has notbeen explained or resolved to the Member’s satisfactionwithin three (3) business days of the Inquiry or anymatter concerning an adverse determination.

A. INQUIRIESThe Inquiry Process is a process prior to the Appealprocess during which Aetna may attempt to answerquestions and/or resolve concerns communicated onbehalf of the Member to the Member’s satisfactionwithin three business days. This process shall not beused for review of an adverse determination, whichmust be reviewed through the Appeal process.

Aetna will address any Inquiry as expeditiously aspossible, and provide a call back within 24 hours. AMember whose Inquiry has not been explained orresolved to the Member’s satisfaction within three (3)business days of the Inquiry, has the right to have theInquiry processed as a Complaint at his/her option,including reduction of an oral Inquiry to writing byAetna, written acknowledgement and writtenresolution of the Complaint.

Aetna maintains records of each Inquirycommunicated by a Member or on their behalf andeach response thereto, for a minimum period of two(2) years. These records are subject to inspection bythe Commissioner of Insurance and the Department ofPublic Health.

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NON-UTILIZATION REVIEW

Aetna Timeframe for Notification of a Non-Utilization Review Adverse Benefit Determination

Type of Claim Aetna Response Time from Receipt of Claim

Urgent Care Claim. A claim for medical care or treatmentwhere delay could seriously jeopardize the life or health ofthe Member, the ability of the Member to regain maximumfunction; or subject the Member to severe pain that cannotbe adequately managed without the requested care ortreatment.

Preservice Claim. A claim for a benefit that requires pre-authorization of the benefit in advance of obtainingmedical care.

Concurrent Care Claim Extension. A request to extend acourse of treatment previously pre-authorized by Aetna.

Concurrent Care Claim Reduction or Termination.Decision to reduce or terminate a course of treatmentpreviously pre-authorized by Aetna.

Post-Service Claim. A claim for a benefit that is not a pre-service claim.

As soon as possible but not later than 72 hours

Within 15 calendar days

If an urgent care claim, as soon as possible but not laterthan 24 hours.

Otherwise,within 15 calendar days

With enough advance notice to allow the Member toAppeal.

Within 30 calendar days

B. COMPLAINTSIf an Inquiry is not resolved in three business days or ifthe Member is dissatisfied with the administrativeservices the Member receives from Aetna or wants tocomplain about a Participating Provider, call or writeMember Services within 30 calendar days of theincident. The Member will need to include a detaileddescription of the matter and include copies of anyrecords or documents that the Member thinks arerelevant to the matter. Aetna will review theinformation and provide the Member with a writtenresponse within 30 calendar days of the receipt of theComplaint, unless additional information is neededand it cannot be obtained within this time frame. Theresponse will tell the Member what the Member needsto do to seek an additional review.

C. APPEALSThe Member will receive written notice about theComplaint or Adverse Determination from the Aetna.The notice will include the reason for the decision andit will explain what steps must be taken if the Memberwishes to Appeal. The notice will also identify theMember’s rights to receive additional information thatmay be relevant to an Appeal.

A Member may also choose to have another person(an authorized representative) make the Appeal on theMember’s behalf by providing Aetna with writtenconsent. All the rights of the Member also extend tothe Member’s authorized representative, whichincludes a Member’s guardian, conservator, holder of apower of attorney, health care agent designatedpursuant to the law, family member, or another personauthorized by the Member in writing or by law withrespect to a specific Appeal or external review,provided that if the Member is unable to designate arepresentative, where such designation wouldotherwise be required, a conservator, holder of apower of attorney, or family member in that order ofpriority may be the Member’s representative or appointanother responsible party to serve as the Member’sauthorized representative. If the authorizedrepresentative is a health care provider, the Membermust specify a named individual who will act on behalfof the authorized representative and a telephonenumber for that individual.

Requests for an Appeal must be made in bytelephone, in person, by mail, or by electronic meanswithin 180 calendar days from the date of the notice.Oral Appeals made by the Member, or the authorizedrepresentative, shall be reduced to writing by Aetnaand a copy thereof forwarded to the Member byAetna within 48 hours of receipt, except where thistime limit is waived or extended by mutual writtenagreement of the Member of the Member’s authorizedrepresentative and Aetna. A writtenacknowledgement of the receipt of an Appeal shall besent to the Member or the Member’s authorizedrepresentative, if any, within 15 business days of saidreceipt, except where an oral Appeal has been reducedto writing by Aetna or this time period is waived orextended by mutual written agreement of the Memberor the Member’s authorized representative and Aetna.

A Member may contact Member Services at the toll-free telephone number on their ID card for assistancein resolving Appeals. A Member may also contact theOffice of Patient Protection at its toll-free telephonenumber 1-800-436-7757, facsimile 1-617-624-5046 orvia the internet site at www.state.ma.us/dph/opp.

Aetna provides for two levels of Appeal plus an optionto seek External Review or Arbitration. The describedtwo-level Appeal process will be completed within 30business days, regardless of the number of levels in theprocess. When an Appeal requires the review ofmedical records, the 30 business day period will notbegin to run until the Member, or the Member’sauthorized representative, submits a signedauthorization for release of medical records andtreatment information. In the event the signedauthorization is not provided by the Member, or theMember’s authorized representative, if any, within 30business days of the receipt of the Appeal, Aetna may,in its discretion, issue a resolution of the Appealwithout review of some or all of the medical records.

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The time limits stated above may be waived or extendedby mutual written agreement of the Member or theMember’s, authorized representative, and Aetna. Any suchagreement shall state the additional time limits, which shall

not exceed 30 business days from the date of theagreement. If additional information is required and theMember does not agree to an extension, Aetna shall makea decision based on the information available.

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Aetna Timeframe for Responding to an Appeal

Please refer to Section C. for information regarding certain types of Claims that may be eligible for anexpedited Appeal Process.

Type of Claim Level One Appeal Level Two Appeal Aetna’s

Aetna’s Response Time Response Time

Level One Appeal from Level Two Appeal from

Receipt of Appeal Receipt of Appeal

Urgent Care Claim. A claim formedical care or treatment where delaycould seriously jeopardize the life orhealth of the Member to gegainmaximum function; or subject theMember to severe pain that cannot beadequately managed withouth therequested care or treatment.

Pre-Service Claim. A claim for abenefit that requires approval of thebenefit in advance of obtainingmedical care.

Concurrent Care Claim Extension. Arequest to extend or a decision toreduce a previously approved couse oftreatment.

Post-Service Claim. Any claim for abenefit that is not a pre-service claim.

Within 36 hours

Review provided by Aetna’s personnelnot involved in making the Complaintor adverse determination.

Within 15 calendar days

Review provided by Aetna’s personnelnot involved in making the Complaintor Adverse B Determination.

Treated like an urgent care claim or apre-service claim depending on thecircumstances

Within 30 business days

Within 36 hours

Review provided by Aetna’s AppealsCommittee.

Within 15 calendar days

Review provided by Aetna’s AppealsCommittee.

Treated like an urgent care claim or apre-service claim depending on thecircumstances

Level I Review provided by Aetna personnel not involved in making theComplaint or adverse determination.Level II Review provided by Aetna’s Appeals Committe.

In at least one level of review of an Appeal, the Appealshall be reviewed with the participation of an individualwho is an actively practicing health care professional inthe same or similar specialty that typically treats themedical condition, performs the procedure, or providesthe treatment that is the subject of the Appeal. TheMember must complete the two levels of Aetna’s reviewbefore bringing a lawsuit against Aetna.

Any second level of Appeal is strictly voluntary and not aprerequisite to filing an external appeal to the Office ofPatient Protection. If the Member decides to Appeal tothe second level, the request must be made in writingwithin 60 calendar days from the date of the notice.

The following chart summarizes some information abouthow the Appeals are handled for different types ofclaims.

If Aetna fails to reduce an oral Appeal to writing andforward a copy to the Member within 48 hours, fails toprovide written acknowledge of the receipt of an Appealto the Member with 15 business days or fails to completethe two-level Appeal process within 30 business days, anAppeal shall be deemed resolved in favor of the Member.Time limits include any extensions made by mutual writtenagreement of the Member, or the Member’s authorizedrepresentative, if any, and Aetna.

A written notice stating the results of the Appeal of theAdverse Determination shall include a substantive clinicaljustification that is consistent with generally acceptedprincipals of professional medical practice that shall at aminimum:

(a) identify the specific information upon which theComplaint or adverse determination was based;

(b) discuss the Member’s presenting symptoms orcondition, diagnosis and treatment interventions andthe specific reasons such medical evidence fails tomeet the relevant medical review criteria;

(c) specify alternative treatment options covered byAetna, if any;

(d) reference and include applicable clinical practiceguidelines and review criteria; and

(e) notify the Member of the Member’s authorizedrepresentative of the procedures for requestingexternal review, including the procedure to requestan expedited external review.

If an Appeal is filed concerning the termination of ongoingcoverage or treatment, the disputed coverage or treatmentshall remain in effect at Aetna’s expense throughcompletion of the internal Appeal process, regardless ofthe original internal Appeal decision. Ongoing coverage ortreatment include only that medical care that, at the time itwas initiated, was authorized by Aetna and does notinclude medical care that was terminated pursuant to aspecific time or episode-related exclusion from theMember’s contact for benefits.

A Member and/or an authorized representative may attendthe Level Two Appeal hearing and question therepresentative of Aetna or any other witnesses, andpresent their case. The hearing will be informal. AMember’s may bring their Physician or other experts totestify. Aetna also has the right to present witnesses.

D. EXPEDITED APPEAL REVIEWPROCEDURES1. In the event the Member is a Hospital inpatient,

Member shall receive a written resolution of anexpedited review, and the opportunity to requestcontinuation of services, of the Appeal prior toHospital discharge. If the expedited review results inan adverse benefit determination regarding thecontinuation of inpatient care, the written resolutionmust inform the Member or the Member’sauthorized representative of the opportunity torequest an expedited external review.

2. In the event the Appeal is of an emergent or urgentnature where the Physician believes that denial ofcoverage for a Medically Necessary service wouldcause serious harm to the Member, an AetnaMedical Director shall review the matter as soon aspossible or within 48 hours, and communicate adecision to the Member by telephone.

3. Provisions for the automatic reversal of decisionsdenying coverage for services or durable medicalequipment, pending the outcome of the Appealprocess, within 48 hours [or earlier for durablemedical equipment at the option of a Physicianresponsible for treatment or proposed treatment ofthe covered patient] of receipt of certification by saidPhysician that, in the Physician’s opinion:

a. the service or use of durable medical equipmentat issue in an Appeal is Medically Necessary; adenial of coverage for such services or durablemedical equipment would create a substantial riskof serious harm to the Member; and

b. such risk of serious harm is so immediate that theprovision of such services or durable medicalequipment should not await the outcome of thenormal Appeal process.

Provisions that require that, in the event a Physicianexercises the option of automatic reversal earlierthan 48 hours for durable medical equipment, thePhysician must further certify as to the specificimmediate and severe harm that will result to theMember absent action within the 48 hour timeperiod.

4. In the event the Member has a terminal illness, anexpedited review of the Appeal will be completedwithin 5 days from the receipt of the Appeal.

If the expedited review process affirms the denial ofcoverage to a Member with a terminal illness, Aetnashall provide the Member, within five (5) businessdays of the decision:

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a. a statement setting forth the specific medical andscientific reasons for denying coverage;

b. a description of alternative treatment, services orsupplies covered by Aetna, if any; and

c. the procedure for the Member to request aconference.

Aetna shall schedule such the conference within 10days of receiving the request for a conference froma Member, at the conference the informationprovided to the Member pursuant to provisions (1)and (2) above shall be reviewed by the Member anda representative of Aetna who has authority todetermine the disposition of the Appeal. Aetnashall permit attendance at the conference of theMember, a designee of the Member or both, or, ifthe Member is a minor or incompetent, the parent,guardian or conservator of the Member asappropriate. The conference shall be held within 5business days if the treating Physician determines,after consultation with Aetna’s Medical Director ordesignee, and based on standard medical practice,that the effectiveness of either the proposedtreatment, services or supplies or any alternativetreatment, services or supplies covered by Aetna,would be materially reduced if not provided at theearliest possible date.

E. EXTERNAL REVIEW PROCESSA Member, who remains aggrieved by an adversedetermination and has exhausted at least one level ofAppeal from the formal Appeal process, may seekfurther review of the Appeal by a review panelestablished by the Office of Patient Protection. Therequest for an external review must be made within 45days of receipt of Aetna’s Appeal determination. Forthe purposes of this provision, an adversedetermination is based upon a review of informationprovided by Aetna to deny, reduce, modify, orterminate an admission, continued inpatient stay, orthe availability of any other health care services, forfailure to meet the requirements for coverage based onMedical Necessity, appropriateness of health caresetting and level of care, or effectiveness.

A Member or the Member’s authorized representative,if any, may request to have his or her request forreview processed as an expedited external review.

1. Any request for an expedited external review shallcontain a certification, in writing, from a Physician,that delay in the providing or continuation of healthcare services that are the subject of a final adversedetermination, would pose a serious and immediatethreat to the health of the Member. Upon findingthat a serious and immediate threat to the Memberexists, the Office of Patient Protection shall qualifysuch request as eligible for an expedited externalreview.

2. A Member seeking a review shall pay a fee of$25.00, to the Office of Patient Protection, whichshall accompany the request for a review. The feemay be waived by said office if it determines thatthe payment of the fee would result in an extremefinancial hardship to the Member.

3. The remained of the cost for an external review shallbe borne by Aetna. Upon completion of theexternal review, the Office of Patient Protection shallbill Aetna the amount established pursuant tocontract between the Department and the assignedexternal review agency minus the $25.00 fee, whichis the Member’s responsibility.

4. In connection with any request for an externalreview, Aetna shall assure that the Member, andwhere applicable the Member’s authorizedrepresentative, have access to any medicalinformation and records relating to the insured, inthe possession of Aetna or under Aetna’s control.

5. Request for review submitted by the Member or theMember’s authorized representative shall:

(a) be on a form prescribed by the Department;

(b) include the signature of the Member or theMember’s authorized representative consentingto the release of medical information;

(c) include a copy of the written final adversedetermination issued by Aetna; and

(d) include the required $25 fee.

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6. If the subject matter of the external review involvesthe termination of ongoing services, the Membermay Appeal to the external review panel to seek thecontinuation of coverage for the terminated serviceduring the period the review is pending. Any suchrequest must be made before the end of the secondbusiness day following receipt of the final adversedetermination. The review panel may order thecontinuation of coverage or treatment where itdetermines that substantial harm to the Member’shealth may result absent such continuation or forsuch other good cause as the review panel shalldetermine. Any such continuation of coverage shallbe at the Aetna’s expense regardless of the finalexternal review determination.

7. The decision of the review panel shall be binding.

The Office of Patient Protection, established by theDepartment of Public Health, is responsible for theadministration and enforcement of certainMassachusetts Managed Care requirements. AMember may obtain the necessary forms to seek anexternal review by contacting the Office of PatientProtection at its toll-free telephone number 1-800-436-7757, facsimile 617-624-5046 or via the internet siteat www.state.ma.us/dph/opp. A Member may alsocontact the Office of Patient Protection to obtain areport detailing, for the previous calendar year, thetotal number of:

a) a list of sources of independently publishedinformation assessing the insured’s satisfactionand evaluating the quality of health care servicesoffered by Aetna.

b) the percentage of Physicians who voluntarily andinvoluntarily terminated participation contractswith the carrier during the previous calendar yearfor which such data has been compiled and thethree most common reasons for voluntary andinvoluntary Physician disenrollment;

c) the percentage of premium revenue expended bythe carrier for health care services provided toinsureds for the most recent year for whichinformation is available; and

d) a report detailing, for the previous calendar year,the total number of:

1. filed Appeals, Appeals that were approvedinternally, Appeals that were denied internally,and Appeals that were withdrawn beforeresolution; and

2. external Appeals pursued after exhausting theinternal Appeals process and the resolution ofall such Appeals.

F. RECORD RETENTIONAetna shall retain the records of all Complaints andAppeals for a period of at least 7 years.

G. FEES AND COSTSNothing herein shall be construed to require Aetna topay counsel fees or any other fees or costs incurred by aMember in pursuing a Complaint or Appeal.

Note: The following section entitled “Dispute Resolution”has been added to the Certificate:

DISPUTE RESOLUTIONAny controversy, dispute or claim between Aetna on theone hand and one or more Interested Parties on the otherhand arising out of or relating to the Group Agreement,whether stated in tort, contract, statute, claim for benefits,bad faith, professional liability or otherwise (“Claim”), shallbe settled by confidential binding arbitration administeredby the American Arbitration Association (“AAA”) before asole arbitrator (“Arbitrator”). Judgment on the awardrendered by the Arbitrator (“Award”) may be entered byany court having jurisdiction thereof. If the AAA declinesto administer the case and the parties do not agree on analternative administrator, a sole neutral arbitrator shall beappointed upon petition to a court having jurisdiction.Aetna and Interested Parties hereby give up their rights tohave Claims decided in a court before a jury.

Any claim alleging wrongful acts or omissions ofParticipating or non-participating Providers shall not includeAetna. A Member must exhaust all Complaint, Appeal andindependent external review procedures prior to thecommencement of arbitration hereunder. No person mayrecover any damages arising out of or related to the failureto approve or provide any benefit or coverage beyondpayment of or coverage for the benefit or coverage where(i) Aetna has made available independent external reviewand (ii) Aetna has followed the reviewer’s decision.Punitive damages may not be recovered as part of a Claimunder any circumstances. No Interested Party mayparticipate in a representative capacity or as a member ofany class in any proceeding arising out of or related to theGroup Agreement. This agreement to arbitrate shall bespecifically enforced even if a party to the arbitration is alsoa party to another proceeding with a third party arising outof the same matter.

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QUALITY ASSURANCE PROGRAMSAetna has developed a comprehensive QualityImprovement Program that places strict attention onquality measurement and improvement and is designed toidentify and respond to the health care concerns of ourmembers. Some of our quality-focused initiatives include:

1. Routine monitoring of quality of service and care,including:

� The performance of medical chart review audits inthe office setting,

� Medical director review of member utilizationpatterns to determine prevalence of acute andchronic conditions, and the need for focuseddisease management programs,

� Comprehensive utilization management and casemanagement programs,

� Review of survey results which assess member andprovider satisfaction levels, and

� Periodic analysis of provider availability and access.

2. Provider certification and recertification, as well asquality performance-based physician and facilitycontracting.

3. Adoption and use of practice guidelines, includingpreventive care recommendations.

4. Health promotion and wellness programs which seekto identify members who may be considered high-risk, and which offer incentives to members whoparticipate and have predetermined goals in fitness,smoking-cessation, and weight loss programs.

5. The uses of an automated tracking system tomonitor member complaints which help identifyopportunities to improve service levels.

6. Programs to monitor and address potentialunderutilization, and denial or delay in providingneeded services.

7. Measuring provider performance to improve thequality of care, assessing medical costs to improvethe value of care, and delivering sophisticated andintegrated data reporting products to customers.

8. The Quality Enhancement rewards primary carephysicians for their scores on several measuresintended to evaluate the quality of care and servicesthe Primary Care Physicians provide to Members.Primary Care Physician offices can earn additionalcompensation for each Member each month basedon the scores received on one or more of thefollowing measures of the Primary Care Physician’soffice: member satisfaction, percentage of memberswho visit the office at least annually, medical recordreviews, the burden of illness of the members thathave selected the primary care physician,management of chronic illnesses like asthma,diabetes and congestive heart failure; whether thephysician is accepting new patients, and participationin Aetna’s electronic claims and referral submission.

9. Annual evaluation of the Quality ImprovementProgram, including voluntary review andaccreditation by the National Committee for QualityAssurance (NCQA), an independent, not-for-profitorganization dedicated to assessing and reporting onthe quality of care and service delivered by managedcare organizations.

EXPERIMENTAL OR INVESTIGATIONALPROCEDURESExperimental or Investigational Procedures means servicesor supplies that are, as determined by Aetna, experimental.A drug, device, procedure or treatment will be determinedto be experimental if:

1. there is not sufficient outcome data available fromcontrolled clinical trials published in the peerreviewed literature to substantiate its safety andeffectiveness for the disease or injury involved; or

2. required FDA approval has not been granted formarketing; or

3. a recognized national medical or dental society orregulatory agency has determined, in writing, that itis experimental or for research purposes; or

4. the written protocol or protocol(s) used by thetreating facility or the protocol or protocol(s) of anyother facility studying substantially the same drug,device, procedure or treatment or the writteninformed consent used by the treating facility or byanother facility studying the same drug, device,procedure or treatment states that it is experimentalor for research purposes; or

5. it is not of proven benefit for the specific diagnosis ortreatment of a member’s particular condition; or

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a) it is not generally recognized by the MedicalCommunity as effective or appropriate for thespecific diagnosis or treatment of a member’sparticular condition; or

b) it is provided or performed in special settings forresearch purposes.

CONTINUITY OF CAREA. Aetna shall notify a member at least 30 days before

the disenrollment of such member’s primary carephysician. A member may continue to be covered forhealth services, consistent with the terms of thecertificate, by such primary care physician for at least30 days after the physician is disenrolled, except fordisenrollment for quality-related reasons or for fraud.A member may change their PCP at any time bycalling the Member Services toll-free telephonenumber listed on their identification card or bywritten or electronic submission of the Aetna changeform. A member may contact Aetna to request achange form or for assistance in completing thatform. The change will become effective upon Aetna’sreceipt and approval of the request.

B. Coverage is provided for any female member who isin her second or third trimester of pregnancy andwhose provider in connection with her pregnancy isinvoluntarily disenrolled, except for disenrollment forquality-related reasons or for fraud, to continuetreatment with said provider, consistent with theterms of the certificate, for the period up to andincluding the member’s first postpartum visit.

C. Coverage is provided for any member who isterminally ill and whose provider in connection withsaid illness is involuntarily disenrolled, except fordisenrollment for quality-related reasons or for fraud,to continue treatment with said provider, consistentwith the terms of the certificate, until the member’sdeath.

D. Coverage is provide for covered services for up to 30days from the effective date of coverage to a newmember for services rendered by a non-participatingprovider if: (1) the member’s employer only offers themember a choice of carriers in which said physician isnot a participating provider, and (2) said physician isproviding the member with an ongoing course oftreatment or is the member’s primary care physician.With respect to a member in her second or thirdtrimester of pregnancy, this provision shall apply toservices rendered through the first postpartum visit.With respect to a member with a terminal illness, thisprovision shall apply to services rendered until death.

E. Aetna may condition coverage of continued treatmentby a provider under subsections A. through D.,inclusive, upon the providers’ agreeing (1) to acceptreimbursement from Aetna at the rates applicableprior to notice of disenrollment as payment in full andnot to impose cost sharing with respect to themember in an amount that would exceed the costsharing that could have been imposed if the providerhad not been disenrolled; (2) to adhere to the qualityassurance standards of Aetna and to provide Aetnawith necessary medical information related to the careprovided; and (3) to adhere to Aetna’s policies andprocedures, including procedures regarding referrals,obtaining prior authorization and providing servicespursuant to a treatment plan, if any, approved byAetna. Nothing in this subsection shall be construedto require the coverage of benefits that would nothave been covered if the provider involved remained aparticipating provider.

SPECIALIST PHYSICIANCovered Benefits include outpatient and inpatient services.If a member requires ongoing care from a specialist, themember may receive a standing referral to such specialist.If PCP in consultation with an Aetna Medical Director andan appropriate specialist determines that a standingreferral is warranted, the PCP shall make the referral to aspecialist. This standing referral shall be pursuant to atreatment plan approved by the Aetna Medical Director inconsultation with the PCP, specialist and member.Coverage is provided for pediatric specialty care, includingmental health care, by persons with recognized expertise inspecialty pediatrics to members requiring such services.

DIRECT ACCESS SPECIALIST BENEFITSThe following services are covered without a referral whenrendered by a participating provider.

1. Routine Gynecological Examination(s). Routinegynecological visit(s) and pap smear(s), as well asmedically necessary evaluations and resultant healthcare services for acute or emergency gynecologicalconditions. The maximum number of visits is providedin the certificate.

2. Open Access to Gynecologists. Benefits are providedto female members for services performed by aparticipating gynecologist for diagnosis and treatmentof gynecological problems and maternity care.

Aetna will not require higher copayments, coinsurance,deductibles or additional cost sharing arrangements fordirect access services provided to a member in the absenceof a referral from the Primary Care Physician.

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PHYSICIAN PROFILINGPhysician profiling information is available from theMassachusetts Board of Registration in Medicine forphysicians licensed to practice in Massachusetts.

CLINICAL GUIDELINES AND UTILIZATIONREVIEW CRITERIAAetna uses a wide range of commercially developed andnationally recognized guidelines and criteria, internallydeveloped guidelines, reference tools, and publishedmedical literature to assist in determining the appropriatelevel of coverage for services.

Local quality committees, composed of communitypracticing physicians and health plan staff review, updateand adopt the review criteria at least annually and morefrequently as necessary.

These criteria may include:

� The Milliman Care Guidelines™.

� InterQual® ISD criteria.

� Western Region Experience of HCIA’s Length of Stay(LOS) Guidelines

� Aetna developed Clinical Policy Bulletins

� Level of Care Assessment Tool (LOCAT)

� American Society of Addictive Medicine PatientManagement Patient Placement Guidelines (ASAM)

� Aetna Internal policies and procedures

INTERPRETER AND TRANSLATIONSERVICESA member may contact Member Services at the telephonenumber listed on their member identification card toreceive information on interpreter and translation servicesrelated to administrative procedures. A TDD# is alsoavailable.

EMERGENCY CARE / URGENT CAREBENEFITSA member has the option of calling the local pre-hospitalemergency medical service system by dialing theemergency telephone access number 911, or its localequivalent, whenever the member is confronted with anemergency medical condition which in the judgment of aprudent layperson would require pre-hospital emergencyservices. A member shall not be discouraged from usingthe local pre-hospital emergency medical service system,the 911 telephone number, or the local equivalent.

Medical transportation is covered for an EmergencyMedical Condition.

The member should notify their primary care physician assoon as possible after emergency or urgent care treatment.Notice given to Aetna, designee or primary care physicianby the attending emergency care physician shall satisfy thisrequirement.

Plan of BenefitsYour plan of benefits will be determined by your plansponsor. Covered services include most types of treatmentprovided by primary care physicians, specialists andhospitals. However, the health plan does exclude and/orinclude limits on coverage for some services, including butnot limited to, cosmetic surgery and experimentalprocedures. In addition, in order to be covered, all services,including the location (type of facility), duration and costsof services, must be medically necessary as definedbelow and as determined by Aetna. The information thatfollows provides general information regarding Aetnahealth plans. For a complete description of the benefitsavailable to you, including procedures, exclusions andlimitations, refer to your specific plan documents, whichmay include the Schedule of Benefits, Certificate ofCoverage, Group Agreement, Group Insurance Certificate,Group Insurance Policy and any applicable riders andamendments to your plan.

Member Cost SharingMembers are responsible for any copayments, coinsuranceand deductibles for covered services. These obligations arepaid directly to the provider or facility at the time theservice is rendered. Copayment, coinsurance anddeductible amounts are listed in your benefits summaryand plan documents.

Role of Primary Care Physicians (“PCPs”)For most HMO plans, members are required to select aPCP who participates in the network. The PCP can provideprimary care as well as coordinate your overall care.Members should consult their PCP when they are sick orinjured to help determine the care that is needed. YourPCP should issue referrals to participating specialists andfacilities for certain services. For some services, your PCP isrequired to obtain prior authorization from Aetna. Exceptfor those benefits described in the plan documents asdirect access benefits, plans with self-referral toparticipating providers (Aetna Open Access or AetnaChoice POS), plans that include benefits fornonparticipating provider services (Aetna Choice POS,USAccess or QPOS), or in an emergency, members willneed to obtain a referral authorization (“referral”) fromtheir PCP before seeking covered nonemergency specialtyor hospital care. Check your plan documents for details.

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Referral PolicyThe following points are important to remember regardingreferrals

� The referral is how the member’s PCP arranges for amember to be covered for necessary, appropriatespecialty care and follow-up treatment.

� The member should discuss the referral with their PCPto understand what specialist services are beingrecommended and why.

� If the specialist recommends any additional treatmentsor tests that are covered benefits, the member mayneed to get another referral from their PCP prior toreceiving the services. If the member does not getanother referral for these services, the member may beresponsible for payment.

� Except in emergencies, all hospital admissions andoutpatient surgery require a prior referral from themember’s PCP and prior authorization by Aetna.

� If it is not an emergency and the member goes to adoctor or facility without a referral, the member mustpay the bill.

� Referrals are valid for 60 days as long as the individualremains an eligible member of the plan.

� In plans without out-of-network benefits, coverage forservices from nonparticipating providers requires priorauthorization by Aetna in addition to a specialnonparticipating referral from the PCP. When properlyauthorized, these services are fully covered, less theapplicable cost-sharing.

� The referral provides that, except for applicable costsharing, the member will not have to pay the chargesfor covered benefits, as long as the individual is amember at the time the services are provided.

Direct AccessUnder Aetna Choice POS, USAccess and QPOS plans amember may directly access nonparticipating providerswithout a PCP referral, subject to cost sharingrequirements. Even so, you may be able to reduce yourout-of-pocket expenses considerably by using participatingproviders. Refer to your specific plan brochure for details.

If your plan does not specifically cover self-referred ornonparticipating provider benefits and you go directly to aspecialist or hospital for nonemergency or nonurgent carewithout a referral, you must pay the bill yourself unless theservice is specifically identified as a direct access benefit inyour plan documents.

Under Aetna Open Access and Aetna Choice POS plans amember may directly access participating providers withouta PCP referral, subject to the terms and conditions of theplan and cost sharing requirements. Participating providerswill be responsible for obtaining any requiredpreauthorization of services from Aetna. Refer to yourspecific plan brochure for details.

Direct Access Ob/Gyn ProgramThis program allows female members to visit anyparticipating obstetrician or gynecologist for a routine wellwoman exam, including a Pap smear, and for obstetric orgynecologic problems. Obstetricians and gynecologists mayalso refer a woman directly to other participating providersfor covered obstetric or gynecologic services. All healthplan preauthorization and coordination requirementscontinue to apply. If your Ob/Gyn is part of anIndependent Practice Association (IPA), a Physician MedicalGroup (PMG), an Integrated Delivery System (IDS) or asimilar organization, your care must be coordinatedthrough the IPA, the PMG or similar organization and theorganization may have different referral policies.

Health Care Provider NetworkAll hospitals may not be considered participating for allservices. Your physician can contact Aetna to identify aparticipating facility for your specific needs. Certain PCPsare affiliated with integrated delivery systems, independentpractice associations (“IPAs”) or other provider groups, andmembers who select these PCPs will generally be referredto specialists and hospitals within that system, associationor group. However, if your medical needs extend beyondthe scope of the affiliated providers, you may requestcoverage for services provided by nonaffiliated networkphysicians and facilities. In order to be covered, servicesprovided by nonaffiliated network providers may requireprior authorization from Aetna and/or the integrateddelivery systems or other provider groups.

Members should note that other health care providers (e.g.specialists) may be affiliated with other providers throughsystems, associations or groups. These systems,associations or groups (“organization”) or, their affiliatedproviders may be compensated by Aetna through acapitation arrangement or other global payment method.The organization then pays the treating provider directlythrough various methods. Members should ask theirprovider how that provider is being compensated forproviding health care services to the member and if theprovider has any financial incentive to control costs orutilization of health care services by the member.

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Transplants and Other ComplexConditionsOur National Medical Excellence Program® and otherspecialty programs help eligible members access coveredtreatment for transplants and certain other complexmedical conditions at participating facilities experienced inperforming these services. Depending on the terms of yourplan of benefits, members may be limited to only thosefacilities participating in these programs when needing atransplant or other complex condition covered.

Emergency CareIf you need emergency care, you are covered 24 hours aday, 7 days a week, anywhere in the world. An emergencymedical condition is one manifesting itself by acutesymptoms of sufficient severity such that a prudentlayperson, who possesses average knowledge of healthand medicine, could reasonably expect the absence ofimmediate medical attention to result in serious jeopardyto the person’s health, or with respect to a pregnantwoman, the health of the woman and her unborn child.

Whether you are in or out of an Aetna HMO service area,we simply ask that you follow the guidelines below whenyou believe you need emergency care.

� Call the local emergency hotline (ex. 911) or go to thenearest emergency facility. If a delay would not bedetrimental to your health, call your PCP. Notify yourPCP as soon as possible after receiving treatment.

� If you are admitted to an inpatient facility, you or afamily member or friend on your behalf should notifyyour PCP or Aetna as soon as possible.

What to Do Outside Your Aetna HMOService AreaMembers who are traveling outside their HMO service areaor students who are away at school are covered foremergency and urgently needed care. Urgent care may beobtained from a private practice physician, a walk-in clinic,an urgent care center or an emergency facility. Certainconditions, such as severe vomiting, earaches, sore throatsor fever, are considered “urgent care” outside your AetnaHMO service area and are covered in any of the abovesettings.

If, after reviewing information submitted to us by theprovider that supplied care, the nature of the urgent oremergency problem does not qualify for coverage, it maybe necessary to provide us with additional information. Wewill send you an Emergency Room Notification Report tocomplete, or a Member Services representative can takethis information by telephone.

Follow-up Care after EmergenciesAll follow-up care should be coordinated by your PCP.Follow-up care with nonparticipating providers is onlycovered with a referral from your PCP and priorauthorization from Aetna. Whether you were treatedinside or outside your Aetna service area, you must obtaina referral before any follow-up care can be covered. Sutureremoval, cast removal, X-rays and clinic and emergencyroom revisits are some examples of follow-up care.

Prescription DrugsIf your plan covers outpatient prescription drugs, your planmay include a preferred drug list (also known as a “drugformulary”). The preferred drug list includes a list ofprescription drugs that, depending on your prescriptiondrug benefits plan, are covered on a preferred basis. Manydrugs, including many of those listed on the preferred druglist, are subject to rebate arrangements between Aetnaand the manufacturer of the drugs. Such rebates are notreflected in and do not reduce the amount a member paysfor a prescription drug. In addition, in circumstances whereyour prescription plan utilizes copayments or coinsurancecalculated on a percentage basis or a deductible, yourcosts may be higher for a preferred drug than they wouldbe for a nonpreferred drug. For information regarding howmedications are reviewed and selected for the preferreddrug list, please refer to Aetna’s website atwww.aetna.com or the Aetna Preferred Drug (Formulary)Guide. Printed Preferred Drug Guide information will beprovided, upon request or if applicable, annually forcurrent members and upon enrollment for new members.Additional information can be obtained by calling MemberServices at the toll-free number listed on your member IDcard. The medications listed on the preferred drug list aresubject to change in accordance with applicable state law.

Your prescription drug benefit is generally not limited todrugs listed on the preferred drug list. Medications that arenot listed on the preferred drug list (nonpreferred ornonformulary drugs) may be covered subject to the limitsand exclusions set forth in your plan documents.

Covered nonformulary prescription drugs may be subjectto higher copayments or coinsurance under some benefitplans. Some prescription drug benefit plans may excludefrom coverage certain nonformulary drugs that are notlisted on the preferred drug list. If it is medically necessaryfor members enrolled in these benefit plans to use suchdrugs, their physicians (or pharmacist in the case ofantibiotics and analgesics) may contact Aetna to requestcoverage as a medical exception. Check your plandocuments for details.

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In addition, certain drugs may require precertification orstep-therapy before they will be covered under someprescription drug benefit plans. Step-therapy is a differentform of precertification which requires a trial of one ormore “prerequisite therapy” medications before a “steptherapy” medication will be covered. If it is medicallynecessary for a member to use a medication subject tothese requirements, the member’s physician can requestcoverage of such drug as a medical exception. In addition,some benefit plans include a mandatory generic drug cost-sharing requirement. In these plans, you may be requiredto pay the difference in cost between a covered brand-name drug and its generic equivalent in addition to yourcopayment if you obtain the brand-name drug.Nonprescription drugs and drugs in the Limitations andExclusions section of the plan documents (received and/oravailable upon enrollment) are not covered, and medicalexceptions are not available for them.

Depending on the plan selected, new prescription drugsnot yet reviewed for possible addition to the preferreddrug list are either available at the highest copay underplans with an “open” formulary, or excluded fromcoverage unless a medical exception is obtained underplans that use a “closed” formulary. These new drugs mayalso be subject to precertification or step-therapy.

Members should consult with their treating physiciansregarding questions about specific medications. Refer toyour plan documents or contact Member Services forinformation regarding terms, conditions and limitations ofcoverage. If you use the mail order prescription program ofAetna Rx Home Delivery, LLC, you will be acquiring theseprescriptions through an affiliate of Aetna. Aetna’snegotiated charge with Aetna Rx Home Delivery® may behigher than Aetna Rx Home Delivery’s cost of purchasingdrugs and providing mail-order pharmacy services. Forthese purposes, Aetna Rx Home Delivery’s cost ofpurchasing drugs takes into account discounts, credits andother amounts that it may receive from wholesalers,manufacturers, suppliers and distributors.

If you use the Aetna Specialty PharmacySM specialty drugprogram, you will be acquiring these prescriptions throughAetna Specialty Pharmacy, LLC, which is jointly owned byAetna and Priority Healthcare, Inc. Aetna’s negotiatedcharge with Aetna Specialty Pharmacy may be higher thanAetna Specialty Pharmacy’s cost of purchasing drugs andproviding specialty pharmacy services. For these purposes,Aetna Specialty Pharmacy’s cost of purchasing drugs takesinto account discounts, credits and other amounts that itmay receive from wholesalers, manufacturers, suppliersand distributors.

BEHAVIORAL HEALTH NETWORK In Massachusetts, Magellan Behavioral Health provides innetwork mental health benefits for Aetna and QPOSMembers.

You may seek treatment from a participating behavioralhealth professional without obtaining a referral from yourPCP. Contact Aetna’s Behavioral Health Contractor,Magellan Behavioral Health (MBH) to:

� find a participating mental health provider in your area

� obtain pre-certification for mental health and substanceabuse services.

Please follow the guidelines below when seeking mentalhealth or substance abuse services:

� Contact MBH first so they can pre-certify and arrangeall routine and urgent behavioral health and substanceabuse services.

� If you have an emergency, please seek care immediately.If you need to go to an emergency room for mentalhealth or substance abuse crisis, please contact MBH assoon as possible for assistance in managing theadmission and any referrals for additional behavioralhealth services that may be needed. Although a PCPreferral is not needed for these types of emergencyroom services, your PCP should be notified.

For more information on how to obtain Mental Health andSubstance Abuse Services please call 1-800-424-6108.

You can also receive information regarding the appropriateway to access the behavioral health care services that arecovered under your specific plan by calling the MemberServices’ toll-free number on your I.D. card. As with othercoverage determinations, you may appeal behavioralhealth care coverage decisions in accordance with theprovisions of your health plan, or applicable state law.

Note: Some employers may have selected a behavioralhealth contractor other than MBH to manage theirbehavioral health benefits. If you have any questions withregard to the name of the behavioral health contractor foryour group, please contact Member Services at 1-888-982-3862. You may also contact your employer’s HumanResource Department.

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How Aetna Compensates Your HealthCare ProviderAll the physicians are independent practicing physiciansthat are neither employed nor exclusively contracted withAetna. Individual physicians and other providers are in thenetwork by either directly contracting with Aetna and/oraffiliating with a group or organization that contract withus.

Participating providers in our network are compensated invarious ways:

� Per individual service or case (fee for service atcontracted rates).

� Per hospital day (per diem contracted rates).

� Capitation (a prepaid amount per member, per month).

� Through Integrated Delivery Systems (IDS), IndependentPractice Associations (IPA), Physician HospitalOrganizations (PHO), Physician Medical Groups (PMG),behavioral health organizations and similar providerorganizations or groups. Aetna pays theseorganizations, which in turn may reimburse thephysician, provider organization or facility directly orindirectly for covered services. In such arrangements, thegroup or organization has a financial incentive tocontrol the cost of care.

One of the purposes of managed care is to manage thecost of health care. Incentives in compensationarrangements with physicians and health care providers areone method by which Aetna attempts to achieve this goal.

In some regions, the Primary Care Physicians can receiveadditional compensation based upon performance on avariety of measures intended to evaluate the quality of careand services the Primary Care Physicians provide toMembers. This additional compensation is based on thescores received on one or more of the following measuresof the Primary Care Physician’s office:

� member satisfaction;

� percentage of members who visit the office at leastannually;

� medical record reviews;

� the burden of illness of the members that have selectedthe primary care physician;

� management of chronic illnesses like asthma;

� diabetes and congestive heart failure;

� whether the physician is accepting new patients; and

� participation in Aetna’s electronic claims and referralsubmission program.

You are encouraged to ask your physicians and otherproviders how they are compensated for their services.

Claims Payment for NonparticipatingProviders and Use of Claims SoftwareIf your plan provides coverage for services rendered bynonparticipating providers, you should be aware thatAetna determines the usual, customary and reasonable feefor a provider by referring to commercially available datareflecting the customary amount paid to most providers fora given service in that geographic area or by accessingother contractual arrangements. If such data is notcommercially available, our determination may be basedupon our own data or other sources. Aetna may also usecomputer software (including ClaimCheck®) and othertools to take into account factors such as the complexity,amount of time needed and manner of billing. You may beresponsible for any charges Aetna determines are notcovered under your plan.

Medically Necessary“Medically necessary” means that the service or supply isprovided by a physician or other health care providerexercising prudent clinical judgment for the purpose ofpreventing, evaluating, diagnosing or treating an illness,injury or disease or its symptoms, and that provision of theservice or supply is:

� Clinically appropriate in accordance with generallyaccepted standards of medical practice in term oftype, frequency, extent, site and duration.

� Considered effective in accordance with generallyaccepted standards of medical practice for theillness, injury or disease; and

� Not primarily for the convenience of the Member, or forthe physician or other health care provider; and

� Not more costly than an alternative service or sequenceof services at least as likely to produce equivalenttherapeutic or diagnostic results as to the diagnosis ortreatment of the illness, injury or disease.

“Generally accepted standards of medical practice”means standards that are based on credible scientificevidence published in peer-reviewed medical literaturegenerally recognized by the relevant medical community.

In the absence of such credible scientific evidence, the[Plan/HMO/Company’s] determinations of whether aservice or supply meets “generally accepted standards ofmedical practice” shall be consistent with physicianspecialty society recommendations and otherwise shall bebased on the views of physicians practicing in relevantclinical areas and any other relevant factors.

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Clinical Policy Bulletins (“CPBs”)Aetna’s CPBs describe Aetna’s policy determinations ofwhether certain services or supplies are medicallynecessary, based upon a review of currently availableclinical information. Clinical determinations in connectionwith individual coverage decisions are made on a case-by-case basis consistent with applicable policies.

Aetna’s CPBs do not constitute medical advice. Treatingproviders are solely responsible for medical advice andtreatment of members. Members should discuss any CPBrelated to their coverage or condition with their treatingprovider.

While Aetna’s CPBs are developed to assist in administeringplan benefits, they do not constitute a description of planbenefits. Each benefit plan defines which services arecovered, which are excluded, and which are subject todollar caps or other limits. Members and their providerswill need to consult the member’s benefit plan todetermine if there are any exclusions or other benefitlimitations applicable to this service or supply. CPBs areregularly updated and are therefore subject to change.Aetna’s CPBs are available online at www.aetna.com.

PrecertificationPrecertification is the process of collecting information priorto inpatient admissions and performance of selectedambulatory procedures and services. The process permitsadvance eligibility verification, determination of coverage,and communication with the physician and/or member. Italso allows Aetna to coordinate the member’s transitionfrom the inpatient setting to the next level of care(discharge planning), or to register members for specializedprograms like disease management, case management, ormaternity management programs. In some instances,precertification is used to inform physicians, members andother health care providers about cost-effective programsand alternative therapies and treatments.

Certain healthcare services, such as hospitalization oroutpatient surgery, require precertification with Aetna.When a member is to obtain services requiringprecertification from a participating provider, the provider isresponsible to precertify those services prior to treatment. Ifyour plan covers self-referred services to network providers,(i.e. Aetna Open Access), or out-of-network benefits andyou may self-refer for covered benefits, it is yourresponsibility to contact Aetna to precertify those serviceswhich require precertification to avoid a reduction inbenefits paid for that service.

Utilization Review/Patient ManagementAetna has developed a patient management program toassist in determining what health care services are coveredunder the health plan and the extent of such coverage.The program assists members in receiving appropriatehealthcare and maximizing coverage for those healthcareservices.

Where such use is appropriate, our UtilizationReview/Patient Management staff uses nationallyrecognized guidelines and resources, such as The MillimanCare Guidelines® to guide the precertification, concurrentreview and retrospective review processes. To the extentcertain Utilization Review/Patient Management functionsare delegated to IDS, IPAs, or other provider groups(“Delegates”), such Delegates utilize criteria that theydeem appropriate. Utilization review/patient managementpolices may be modified to comply with applicable statelaw.

Only medical directors make decisions denying coveragefor services for reasons of medical necessity. Coveragedenial letters for such decisions delineate any unmetcriteria, standards and guidelines, and inform the providerand member of the appeal process.

Concurrent Review

The concurrent review process assesses the necessity forcontinued stay, level of care, and quality of care formembers receiving inpatient services. All inpatient servicesextending beyond the initial certification period will requireConcurrent Review.

Discharge Planning

Discharge planning may be initiated at any stage of thepatient management process and begins immediatelyupon identification of post-discharge needs duringprecertification or concurrent review. The discharge planmay include initiation of a variety of services/benefits to beutilized by the member upon discharge from an inpatientstay.

Retrospective Record Review

The purpose of retrospective review is to retrospectivelyanalyze potential quality and utilization issues, initiateappropriate follow-up action based on quality or utilizationissues, and reviews all appeals of inpatient concurrentreview decisions for coverage of health care services.Aetna’s effort to manage the services provided to membersincludes the retrospective review of claims submitted forpayment, and of medical records submitted for potentialquality and utilization concerns.

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Complaints, Appeals and ExternalReview*Filing a Complaint or Appeal

Aetna is committed to addressing members’ coverageissues, complaints and problems. If you have a coverageissue or other problem, call Member Services at the tollfree number on your ID card. You can also contactMember Services through the Internet at:www.aetna.com. If Member Services is unable to resolveyour issue to your satisfaction, it will be forwarded to theappropriate department for handling.

If you are dissatisfied with the outcome of your initialcontact, you may file an appeal. If you are not satisfiedafter filing a formal appeal, you may request a second levelappeal of the decision. Your appeal will be decided inaccordance with the procedures applicable to your planand applicable state law. Refer to your plan documents forfurther details regarding your plan’s appeal procedure.

External Review

Aetna established an external review process to giveeligible members the opportunity of requesting anobjective and timely independent review of certaincoverage denials. Once the applicable appeal process hasbeen exhausted, eligible members may request an externalreview of the decision if the coverage denial, for which themember would be financially responsible, involves morethan $500, and is based on lack of medical necessity or onthe experimental or investigational nature of the proposedservice or treatment. Standards may vary by state, if astate-mandated external review process exists and appliesto your plan.

An Independent Review Organization (IRO) will assign thecase to a physician reviewer with appropriate expertise inthe area in question. After all necessary information issubmitted, an external review generally will be decidedwithin 30 calendar days of the request.

Expedited reviews are available when a member’s physiciancertifies that a delay in service would jeopardize themember’s health. Once the review is complete, the planwill abide by the decision of the external reviewer. The costfor the review will be borne by Aetna (except where statelaw requires members to pay a filing fee as part of thestate-mandated program).

Certain states mandate external review of additionalbenefit or service issues; some may require a filing fee. Inaddition, certain states mandate the use of their ownexternal review process for medical necessity andexperimental/ investigational coverage decisions. Thesestate mandates may not apply to self-funded plans. Forfurther details regarding your plan’s appeal process and theavailability of an external review process, call the MemberServices toll-free number on your ID card or visit ourwebsite www.aetna.com where you may obtain anexternal review request form. You also may call your stateinsurance or health department or consult their website foradditional information regarding state mandated externalreview procedures.

Confidentiality and Privacy NoticesAetna considers personal information to be confidentialand has policies and procedures in place to protect itagainst unlawful use and disclosure. By “personalinformation,” we mean information that relates to amember’s physical or mental health or condition, theprovision of health care to the member, or payment for theprovision of health care to the member. Personalinformation does not include publicly available informationor information that is available or reported in asummarized or aggregate fashion but does not identify themember.

When necessary or appropriate for your care or treatment,the operation of our health plans, or other relatedactivities, we use personal information internally, share itwith our affiliates, and disclose it to health care providers(doctors, dentists, pharmacies, hospitals and othercaregivers), payors (health care provider organizations,employers who sponsor self-funded health plans or whoshare responsibility for the payment of benefits, and otherswho may be financially responsible for payment for theservices or benefits you receive under your plan), otherinsurers, third-party administrators, vendors, consultants,government authorities, and their respective agents.

These parties are required to keep personal informationconfidential as provided by applicable law. Participatingnetwork providers are also required to give you access toyour medical records within a reasonable amount of timeafter you make a request. Some of the ways in whichpersonal information is used include: claims payment;utilization review and management; medical necessityreviews; coordination of care and benefits; preventivehealth; early detection; disease and case management;quality assessment and improvement activities; auditingand antifraud activities; performance measurement andoutcomes assessment; health claims analysis and reporting;health services research; data and information systems

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*This Complaint Appeal and External Review process may not apply if your plan is self-funded. Contact your Benefits Administrator if you have anyquestions.

management; compliance with legal and regulatoryrequirements; formulary management; litigationproceedings; transfer of policies or contracts to and fromother insurers, HMOs and third party administrators;underwriting activities; and due diligence activities inconnection with the purchase or sale of some or all of ourbusiness.

We consider these activities key for the operation of ourhealth plans. To the extent permitted by law, we use anddisclose personal information as provided above withoutmember consent. However, we recognize that manymembers do not want to receive unsolicited marketingmaterials unrelated to their health benefits. We do notdisclose personal information for these marketing purposesunless the member consents. We also have policiesaddressing circumstances in which members are unable togive consent.

To obtain a hard copy of our Notice of Privacy Practices,which describes in greater detail our practices concerninguse and disclosure of personal information, please write toAetna’s Legal Support Services Department at 151Farmington Avenue, W121, Hartford, CT 06156. You canalso visit our Internet site at www.aetna.com. You canlink directly to the Notice of Privacy Practices by selectingthe “Privacy Notices” link at the bottom of the page.

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Pre-existing Conditions ExclusionProvision (only for plans containing suchprovision)

Providing Proof of Creditable CoverageGenerally, you will have received a certification of priorhealth coverage from your prior medical plan as proof ofyour prior coverage. You should retain that certificationuntil you submit a medical claim. When a claim fortreatment of a potential pre-existing condition is received,the claim office will request from you that certification ofprior health coverage, which will be used to determine ifyou have creditable coverage at that time.

You may request a certification of prior healthcoverage from your prior carrier(s) with whom you hadcoverage within the past two years. Our Service Center canassist you with this and can provide you with the type ofinformation that you will need to request from your priorcarrier. The Service Center may also request informationfrom you regarding any pre-existing condition for whichyou may have been treated in the past and otherinformation that will allow them to determine if you havecreditable coverage. This is to advise you that a pre-existingconditions exclusion period may apply to you, if a pre-existing conditions exclusion provision is included in theGroup Plan that you are or become covered under. If yourplan contains pre-existing conditions exclusion, suchexclusion may be waived for you if you have priorcreditable coverage.

Note: If a state law mandates a gap period greater than90 days, that longer gap period will be used to determinecreditable coverage. If you have any questions regardingthe determination of whether or not pre-existingconditions exclusion applies to you, please call the MemberServices telephone number on your ID card.

Creditable CoverageCreditable coverage includes coverage under a grouphealth plan (including a governmental or church plan),health insurance coverage (either group or individualinsurance), Medicare, Medicaid, military-sponsored healthcare (TRICARE) a program of the Indian Health Service, aState health benefit risk pool, the FEHBP, a public healthplan as defined in the regulations, and any health benefitplan under section 5(c) of the Peace Corps Act. Notincluded as creditable coverage is any coverage that isexempt from the law (e.g., dental only coverage or dentalcoverage that is provided in a separate plan or even if inthe same plan as medical, is separately elected and resultsin additional premium).

If you had prior creditable coverage within the 90 daysimmediately before the date you enrolled under this plan,then the pre-existing conditions exclusion in your plan, ifany, will be waived. The determination of the 90 dayperiod will not include any waiting period that may beimposed by your employer before you are eligible forcoverage.

If you had no prior creditable coverage within the 90days prior to your enrollment date (either because you hadno prior coverage or because there was more than a 90day gap from the date your prior coverage terminated toyour enrollment date), we will apply your plan’s pre-existing conditions exclusion (to a maximum period of 12months).

Special Enrollment PeriodsDue to Loss of Coverage

If you are eligible for coverage under your employer’smedical plan but do/did not enroll in that medical planbecause you had other medical coverage, and you losethat other medical coverage, you will be allowed to enrollin the current medical plan during special enrollmentperiods after your initial eligibility period, if certainconditions are met. These special enrollment rules apply to

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Health Insurance Portability andAccountability Act Member Notice* The following information is provided to inform the member of certain provisionscontained in the Group Health Plan, and related procedures that may be utilized by themember in accordance with Federal law.

* While this member notice is believed to be accurate as of the publication date, it is subject to change. Please contact the Member ServicesDepartment, if you have any questions.

employees and/or dependents who are eligible, but notenrolled for coverage, under the terms of the plan.

An employee or dependent is eligible to enroll during aspecial enrollment period if each of the followingconditions are met:

� When you declined enrollment for you or yourdependent, you stated in writing that coverage underanother group health plan or other health insurancewas the reason for declining enrollment, if the employerrequired such written notice and you were given noticeof the requirement and the consequences of notproviding the statement; and

� When you declined enrollment for you or yourdependent, you or your dependent had COBRAcontinuation coverage under another plan and thatCOBRA continuation coverage has since beenexhausted; or

� If the other coverage that applied to you or yourdependent when enrollment was declined was notunder a COBRA continuation provision, either the othercoverage has been terminated as a result of the loss ofeligibility or employer contributions toward thatcoverage have been terminated. Loss of eligibilityincludes a loss of coverage as a result of legalseparation, divorce, death, termination of employment,or reduction in hours of employment.

For Certain Dependent Beneficiaries

If your Group Health Plan offers dependent coverage, it isrequired to offer a dependent special enrollment period forpersons becoming a dependent through marriage, birth, oradoption or placement for adoption. The dependentspecial enrollment period will last for 31 days from thedate of the marriage, birth, adoption or placement foradoption. The dependent may be enrolled during that timeas a dependent of the employee. If the employee is eligiblefor enrollment, but not enrolled, the employee may alsoenroll at this time. In the case of the birth or adoption of achild, the spouse of the individual also may be enrolled asa dependent of the employee if the spouse is otherwiseeligible for coverage but not already enrolled. If anemployee seeks to enroll a dependent during the specialenrollment period, the coverage would become effectiveas of the date of birth, of adoption or placement foradoption, or marriage.

Special Enrollment Rules

To qualify for the special enrollment, individuals who meetthe above requirements must submit a signed request forenrollment no later than 31 days after one of the eventsdescribed above. The effective date of coverage forindividuals who lost coverage will be the date of thequalifying event. If you seek to enroll a dependent duringthe special enrollment period, coverage for your

dependent (and for you, if also enrolling) will becomeeffective as of the date that the qualifying event occurred,(for marriage, as of the enrollment date) once thecompleted request for enrollment is received.

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2200.28.317.1 (7/05)

As of 7/1/2005 this addendum replaces the Health Insurance Portability andAccountability Act Member Notice that appears elsewhere in this disclosure. See yourBenefit Summary for information regarding preexisting conditions exclusions.The following information is provided to inform the member of certain provisions contained in the Group Health Plan, andrelated procedures that may be utilized by the member in accordance with federal law.

Special Enrollment RightsIf you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance orgroup health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependentslose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage).However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after theemployer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be ableto enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth,adoption or placement for adoption.

To request special enrollment or obtain more information, contact your benefits administrator.

Request for Certificate of Creditable CoverageMembers of insured plan sponsors and members of self insured plan sponsors who have contracted with us to provideCertificates of Prior Health Coverage have the option to request a certificate. This applies to terminated members, and itapplies to members who are currently active but who would like a certificate to verify their status. Terminated members canrequest a certificate for up to 24 months following the date of their termination. Active member can request a certificate atany time. To request a Certificate of Prior Health Coverage, please contact Member Services at the telephone number on theback of your ID card.

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*While this Member Notice is believed to be accurate as of the publication date, it is subject to change. Please contact the Member Services departmentif you have any questions.

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Notes

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While this information is believed to be accurate as of theprint date, it is subject to change.

This material is for informational purposes only and isneither an offer of coverage nor medical advice. It containsonly a partial, general description of plan benefits orprograms and does not constitute a contract. Aetnaarranges for the provision of health care services. However,Aetna itself is not a provider of health care services andtherefore, cannot guarantee any results or outcomes.Consult the plan documents [Group Agreement, GroupInsurance Certificate, Schedule of Benefits, Certificate ofCoverage, Group Policy] to determine governingcontractual provisions, including procedures, exclusionsand limitations relating to the plan. The availability of aplan or program may vary by geographic service area andby plan design. These plans contain exclusions and somebenefits are subject to limitations or visit maximums.

With the exception of Aetna Rx Home Delivery®, allparticipating physicians, hospitals and other health careproviders are independent contractors and are neitheragents nor employees of Aetna. Aetna Rx Home Delivery,LLC. is a subsidiary of Aetna Inc. The availability of anyparticular provider cannot be guaranteed, and providernetwork composition is subject to change. Notice of thechange shall be provided in accordance with applicablestate law. Certain primary care physicians are affiliated withintegrated delivery systems or other provider groups (suchas independent practice associations and physician-hospitalorganizations), and members who select these providerswill generally be referred to specialists and hospitals withinthose systems or groups. However, if a system or groupdoes not include a provider qualified to meet member’smedical needs, member may request to have servicesprovided by nonsystem or nongroup providers. Member’srequest will be reviewed and will require priorauthorization from the system or group and/or Aetna to bea covered benefit.

The NCQA Accreditation Seal is a recognized symbol ofquality. NCQA recognition seals appear in the providerdirectory next to those providers who have been dulyrecognized. NCQA provider recognitions are subject tochange.

For up-to-date information, please visit our DocFind® onlineprovider directory at www.aetna.com or visit the NCQA’snew top-level recognition listing at recognition.ncqa.org.

Aetna is the brand name used for products and servicesprovided by one or more of the Aetna group of subsidiarycompanies. In-network and out-of-network referredbenefits are underwritten by Aetna Health Inc. Self-referred benefits are underwritten by Corporate HealthInsurance Company. For self-funded accounts, benefitscoverage offered by your employer, with administrativeservices only provided by Aetna Life Insurance Company.

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Notice to Members

If you need this material translated into another language, please call Member Services at 1-888-982-3862.

Si usted necesita este documento en otro idioma, por favor llame a Servicios al Miembro al 1-888-982-3862.