SOME HOSPITALS AND OTHER PROVIDERS DO …

1 aetna HEALTH OF CALIFORNIA CAMINO RAMONSAN RAMON, CA 945831-800-756-7039 PLEASE READ THIS DISCLOSURE BROCHURE CAREFULLY. IT CONTAINS IMPORTANTINFORMATION YOU SHOULD KNOW BEFORE YOU ENROLLTHIS DISCLOSURE FORM IS ONLY A SUMMARY.* * THE EVIDENCE OF COVERAGE CONTAINS THETERMS AND CONDITIONS OF COVERAGE AND SHOULD BE CONSULTED TO DETERMINEGOVERNING CONTRACTUAL PROVISIONS. * * YOU HAVE A RIGHT TO VIEW THE EVIDENCE OF COVERAGE PRIOR TO ENROLLMENT IN THISPLAN. YOU MAY REQUEST THE EVIDENCE OF COVERAGE FROM YOUR EMPLOYER GROUP OR BYCONTACTING aetna U. S. HEALTHCARE OF CALIFORNIA THIS DISCLOSURE BROCHURE AND THE ACCOMPANYING SAMPLE EVIDENCE OF COVERAGESHOULD BE READ COMPLETELY AND CAREFULLY. INDIVIDUALS WITH SPECIAL HEALTH CARENEEDS SHOULD READ CAREFULLY THOSE SECTIONS THAT APPLY TO INFORMATION ABOUT THE BENEFITS OF THIS PLAN MAY BE OBTAINED BYCALLING 1-800-756-7039.*THE ATTACHED SAMPLE EVIDENCE OF COVERAGE AND THIS DISCLOSURE FORMARE FOR YOUR INFORMATION ONLY, THE ACTUAL EVIDENCE OF COVERAGEAPPLICABLE TO YOUR PLAN MAY CONTAIN ADDITIONAL OPTIONAL BENEFITSSELECTED BY YOUR STATEMENT DESCRIBING aetna HEALTH OF CALIFORNIA S POLICIES AND PROCEDURES FORPRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BEFURNISHED TO MEMBERS UPON HOSPITALS AND OTHER PROVIDERS DO NOT PROVIDE ONE OR MORE OFTHE FOLLOWING SERVICES THAT MAY BE COVERED UNDER YOUR PLANCONTRACT AND THAT YOU OR YOUR FAMILY MEMBER MIGHT NEED: FAMILYPLANNING; CONTRACEPTIVE SERVICES, INCLUDING EMERGENCYCONTRACEPTION; STERILIZATION, INCLUDING TUBAL LIGATION AT THE TIME OFLABOR AND DELIVERY; INFERTILITY TREATMENTS; OR ABORTION.

2 YOUSHOULD OBTAIN MORE INFORMATION BEFORE YOU ENROLL. CALL YOURPROSPECTIVE DOCTOR, MEDICAL GROUP, INDEPENDENT PRACTICEASSOCIATION, OR CLINIC, OR CALL THE HEALTH PLAN AT THE TOLL FREEMEMBER SERVICES NUMBER LISTED ON YOUR ID CARD TO ENSURE THAT YOUCAN OBTAIN THE HEALTH CARE SERVICES THAT YOU DISCLOSURE BROCHURE 3/01: PART (01/04)3 HMO/CA DISCLOSURE BROCHURE 3/01: PART (01/04)INTRODUCTIONThe information which follows provides general information regarding aetna Health health plans. Youshould refer to your specific plan documents for additional information regarding the operation of yourplan. Additional important information regarding Your Primary Care Physician (PCP), Participating PROVIDERS Referrals and authorization, Requesting continuity of care or standing referrals, Facilities, and Grievance Proceduresmay be found in the attached sample Evidence of Coverage (EOC).Information about how the HMO determines medical necessity may be found at the beginning of the Covered Benefits section of the attached sample Evidence of can find additional information including provider directories, the prescription drug formulary,coverage policy bulletins and OTHER important information at our website, You can contact the California Department of Managed Care at Eligibility, covered benefits, medical necessity, precertification, concurrent review, retrospective recordreview and all OTHER terms and conditions of your health plan are determined at the sole discretion ofAetna Health (or its designee).

3 This means that some services recommended by your health professionalmay not be deemed covered benefits as determined by aetna PCPs are affiliated with integrated delivery systems, independent practice associations ( IPAs ) orother provider groups, and members who select these PCPs will generally be referred to specialists andhospitals within that system, association or group. However, if your medical needs extend beyond the scopeof the affiliated PROVIDERS , you may request coverage for services provided by non-affiliated networkphysicians and facilities. In order to be covered, services provided by non-affiliated network PROVIDERS mayrequire pre-approval from aetna Health and/or the integrated delivery systems or OTHER provider find a primary care physician (PCP), go to our online provider directory, DocFind , located DocFind is available 24 hours a day, 7 days a week and isupdated three times a week. With DocFind s easy to use format, you can search for a provider online byname, specialty, gender and/or hospital affiliation.

4 A printed directory will also be OF PRIMARY CARE PHYSICIANS ( PCP )You should consult your primary care physician ( PCP ) when you are sick or injured to help determinethe care that is needed. You should refer to your plan documents to determine covered benefits,exclusions and limitations under your benefits plan. Except for those benefits described in the plandocuments as direct access benefits, or in an emergency, you need to obtain a referral authorization( referral ) from your PCP before seeking covered non-emergency specialty or hospital care. The following points are important to remember regarding referrals: The referral is how your PCP arranges for you to be covered for necessary, appropriatespecialty care and follow-up treatment. 4 HMO/CA DISCLOSURE BROCHURE 3/01: PART (01/04) You should discuss the referral with your PCP to understand what specialist services are beingrecommended and why.

5 If the specialist recommends any additional treatments or tests that are covered benefits, you must getanother referral from your PCP prior to receiving the services. If you do not get another referral forthese services, you will be responsible for payment. Except in emergencies, all hospital admissions and outpatient surgery require a prior referral fromyour PCP and prior approval by the plan. If it is not an emergency and you go to a doctor or facility without a referral, you must pay the bill. Referrals are valid for 90 days as long as the individual remains an eligible member of the plan. Coverage for services from nonparticipating PROVIDERS requires prior approval by aetna Health inaddition to a special nonpar referral from the PCP. These services are only covered when AetnaHealth has determined that there is no participating provider with appropriate training and experiencefor your particular needs. When properly authorized, these services are fully covered, less theapplicable copayment.

6 The referral provides that, except for applicable copayments, you will not have to pay the charges forcovered benefits, as long as you are a member at the time the services are provided. HEALTH CARE PROVIDER NETWORKWhen you use the Provider Directory or DocFind, you will note that certain health care PROVIDERS areaffiliated with OTHER PROVIDERS through systems, associations or groups. These systems, associations orgroups ( organization ) or, their affiliated PROVIDERS may be compensated by aetna Health through acapitation arrangement or OTHER global payment method. The organization then pays the treating providerdirectly through various methods. You should ask your provider how that provider is being compensatedfor providing health care services to you and if the provider has any financial incentive to control costs orutilization of health care services by summary of any agreement or contract between HMO and any health care provider will be madeavailable upon request by calling the Member Services telephone number on your ID card.

7 The summarywill not include financial agreements as to actual rates, reimbursements, charges, or fees negotiated byHMO and the provider. The summary will include a category or type of compensation paid by HMO toeach class of health care provider under contract with HMO. COVERED BENEFITSIn order to be covered, all services, including the location (type of facility), duration and costs of services,must be medically necessary as defined in the plan documents and as determined solely by aetna consult the section at the beginning of the Covered Benefits section in the Sample EOC included inthis Disclosure Brochure for additional information about how the HMO determines medical necessity. MEDICAL NECESSITYIn order to be covered, all services, including the location (type of facility), duration and costs of services,must be medically necessary as defined in the plan documents and as determined solely by aetna consult the section at the beginning of the Covered Benefits section in the Sample EOC attached tothis document for additional information about how the HMO determines medical DISCLOSURE BROCHURE 3/01: PART (01/04)DIRECT ACCESS PROGRAM* This program allows female members to visit any participating gynecologist for a routine well-womanexam, including a Pap smear (if appropriate) and an unlimited number of visits for gynecologic problemsand follow-up care as described in your benefits plan.

8 Gynecologists may also refer a woman directlyfor covered gynecologic services without the patient s having to go back to her participating primary carephysician. Women may also choose to receive the care described in the Direct Access Program fromtheir primary care physician.* If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician MedicalGroup (PMG) or a similar organization, you must select your participating gynecologist orobstetrician in the IPA, the PMG or the similar organization. MENTAL HEALTH/SUBSTANCE ABUSEB ehavioral health care benefits ( , coverage for treatment or care for mental disease or illness, alcoholabuse and/or substance abuse) are managed by aetna Health or an independently contractedorganization. aetna Health or the independently contracted organization makes initial coveragedeterminations and coordinates referrals. Any behavioral health care referrals will generally be made toproviders affiliated with the organization, unless your needs for covered services extend beyond thecapability of the affiliated PROVIDERS .

9 Your coverage will not exceed the maximum number of visits inyour Schedule of Benefits or allowed in your Evidence of Coverage. aetna Health or its contracted organization may use prior authorizations and ongoing reviews to limitthe number of outpatient mental health visits or inpatient days to the minimum it deems to be coveredbenefits that are medically necessary independent of the maximum number of visits described in yourSchedule of Benefits. This means that you may not receive coverage for the maximum number of visitsor days specified in your Schedule of Benefits, or the number of visits or days that you and your healthprofessional believe to be appropriate, for a single course of treatment or episode. For example,psychotherapeutic outpatient treatment for depression may be considered a covered benefit for eightindividual visits, but aetna Health or its contracted organization may, through concurrent review, decideit will not cover any further treatment, even when the Schedule of Benefits states that the maximumnumber of outpatient visits is up to twenty (20) sessions per year.

10 Effective July 1, 2000, treatment(s) for serious mental illness and serious emotional disturbances ofa child, as defined in Health & Safety Code, Section , are not subject to the annual maximumsshown on your Schedule of Benefits. These treatments are still subject to: a) prior authorizations andongoing review to determine coverage; and, b) your plan s maximum lifetime benefits, copayments andindividual and family deductibles, if can receive information regarding the appropriate way to access the behavioral health care servicesthat are covered under your specific plan by calling the toll-free number on your card. As with othercoverage determinations, you may appeal behavioral health care coverage decisions in accordance withthe provisions of your health plan, and applicable state ACCESS UNDER QPOS AND USACCESS PLANS ONLYU nder USAccess and QPOS plans, you may go directly to a specialist or hospital without a referral forcertain covered benefits. However, you will generally be responsible for a deductible and coinsuranceunder these plans.