Tipton Academy

PLAN DESIGN

Customer Name: The Romine Group

Proposed Effective Date: 01-01-2015

Policy Period: 12

Data Source ID: Q3188722 - 1 - All Employees/NC/250/4629MIPP#2139

Option: $250 PPO Plan Option

Plan: PPO Plan

Location(s): Michigan

Specialty Networks Included: None Quoted

Organization Name: Aetna




The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:21 PM Page 1
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $250 Individual $10,000 Individual $500 Family $20,000 Family All covered expenses accumulate separately toward the preferred or non-preferred Deductible. Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost sharing for certain services, as indicated in the plan, are excluded from charges to meet the Deductible. Pharmacy expenses do not apply towards the Deductible. The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met by a combination of family members; however no single individual within the family will be subject to more than the individual Deductible amount. Member Coinsurance 10% 50% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $750 Individual $12,000 Individual $1,500 Family $24,000 Family All covered expenses accumulate separately toward the preferred or non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Pharmacy expenses apply towards the Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, copays, and deductibles (except any penalty amounts) may be used to satisfy the Payment Limit. The family Payment Limit is a cumulative Payment Limit for all family members. The family Payment Limit can be met by a combination of family members; however no single individual within the family will be subject to more than the individual Payment Limit amount. Lifetime Maximum Unlimited except where otherwise indicated. Payment for Non-Preferred Care** Not Applicable Professional: 105% of Medicare Facility: 140% of Medicare Primary Care Physician Selection Not Applicable Not Applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $400 per occurrence. Referral Requirement None None PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK Routine Adult Physical Exams/ Immunizations Covered 100%; deductible waived 50%; after deductible 1 exam every 12 months for members age 22 to age 65; 1 exam every 12 months for adults age 65 and older. Routine Well Child Exams/Immunizations Covered 100%; deductible waived 50%; after deductible 7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12 months of life, 1 exam per year thereafter to age 22. Routine Gynecological Care Exams Covered 100%; deductible waived 50%; after deductible Recommended: One exam per calendar year. Includes routine tests and related lab fees. Routine Mammograms Covered 100%; deductible waived 50%; after deductible Recommended: One baseline mammogram for covered females age 35-39, one mammogram per calendar year for covered females age 40 and over. Women's Health Covered 100%; deductible waived 50%; after deductible Includes: Screening for gestational diabetes, HPV (Human- Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies and counseling.


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:21 PM Page 2
Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam Covered 100%; deductible waived 50%; after deductible Prostate-specific Antigen Test Covered 100%; deductible waived 50%; after deductible Colorectal Cancer Screening Covered under Routine Adult Exams Covered under Routine Adult Exams Recommended: For all members age 50 and over. Routine Eye Exams Covered 100%; deductible waived Not Covered 1 routine exam per 24 months. Routine Hearing Exams Not Covered Not Covered Routine Hearing Screening Covered 100%; deductible waived 50%; after deductible PHYSICIAN SERVICES IN-NETWORK OUT-OF-NETWORK Office Visits to non-Specialist $30 office visit copay; deductible waived 50%; after deductible Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits $30 office visit copay; deductible waived 50%; after deductible Pre-Natal Maternity Covered 100%; deductible waived Covered according to standard claim practice. E-visit to Non-Specialist $30 copay; deductible waived 50%; after deductible An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through our authorized internet E-visit service vendor. E-visit to Specialist $30 copay; deductible waived 50%; after deductible An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through our authorized internet E-visit service vendor. Walk-in Clinics $30 office visit copay; deductible waived 50%; after deductible Walk-in Clinics are network, free-standing health care facilities. They are an alternative to a physician's office visit for treatment of unscheduled, non-emergency illnesses and injuries and the administration of certain immunizations. It is not an alternative for emergency room services or the ongoing care provided by a physician. Neither an emergency room, nor the outpatient department of a hospital, shall be considered a Walk-in Clinic. Allergy Testing Member cost sharing is based on the type of service performed and the place of service where it is rendered; deductible waived Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Allergy Injections Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible DIAGNOSTIC PROCEDURES IN-NETWORK OUT-OF-NETWORK Diagnostic X-ray 10%; after deductible 50%; after deductible If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Diagnostic Laboratory 10%; after deductible 50%; after deductible If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Diagnostic Outpatient Complex Imaging 10%; after deductible 50%; after deductible EMERGENCY MEDICAL CARE IN-NETWORK OUT-OF-NETWORK Urgent Care Provider $50 copay; deductible waived 50%; after deductible Non-Urgent Use of Urgent Care Provider Not Covered Not Covered


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:21 PM Page 3
Emergency Room $150 copay; deductible waived Same as preferred care Non-Emergency Care in an Emergency Room Not Covered Not Covered Emergency Use of Ambulance $100 copay; after deductible $100 copay; after deductible Non-Emergency Use of Ambulance Not Covered Not Covered HOSPITAL CARE IN-NETWORK OUT-OF-NETWORK Inpatient Coverage 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Inpatient Maternity Coverage (includes delivery and postpartum care) 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Hospital Expenses 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Outpatient Surgery 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Outpatient Surgery - Freestanding Facility 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. MENTAL HEALTH SERVICES IN-NETWORK OUT-OF-NETWORK Inpatient 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient $30 copay; deductible waived 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. ALCOHOL/DRUG ABUSE SERVICES IN-NETWORK OUT-OF-NETWORK Inpatient 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Residential Treatment Facility 10%; after deductible 50%; after deductible Treatment Facility 10%; after deductible 50%; after deductible Outpatient $30 copay; deductible waived 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. OTHER SERVICES IN-NETWORK OUT-OF-NETWORK Convalescent Facility 10%; after deductible 50%; after deductible Limited to 60 days per calendar year. The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Home Health Care 10%; after deductible 50%; after deductible Limited to 60 visits per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Hospice Care - Outpatient 10%; after deductible 50%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Private Duty Nursing - Outpatient Not Covered Not Covered Outpatient Short-Term Rehabilitation $30 copay; deductible waived 50%; after deductible Includes Speech, Physical, and Occupational Therapy, limited to 60 visits per calendar year. Spinal Manipulation Therapy $30 copay; deductible waived 50%; after deductible Limited to 20 visits per calendar year.


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:21 PM Page 4
Autism Behavioral Therapy $30 copay; deductible waived 50%; after deductible Covered same as any other Outpatient Mental Health benefit Autism Applied Behavior Analysis $30 copay; deductible waived 50%; after deductible Covered same as any other Outpatient Mental Health benefit with no age or visit limitations. Autism Physical Therapy $30 copay; deductible waived 50%; after deductible Visits combined with Short Term Rehabilitation. Autism Occupational Therapy $30 copay; deductible waived 50%; after deductible Visits combined with Short Term Rehabilitation. Autism Speech Therapy $30 copay; deductible waived 50%; after deductible Visits combined with Short Term Rehabilitation. Durable Medical Equipment 10%; after deductible 50%; after deductible Diabetic Supplies -- (if not covered under Pharmacy benefit) Covered same as any other medical expense. Covered same as any other medical expense. Generic FDA-approved Women's Contraceptives Covered 100%; deductible waived Not Covered Contraceptive drugs and devices not obtainable at a pharmacy Covered 100%; deductible waived Covered same as any other medical expense. Transplants 10%; after deductible 50%; after deductible Preferred coverage is provided at an IOE contracted facility only. Non-Preferred coverage is provided at a Non-IOE facility. Bariatric Surgery Not Covered Not Covered The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. "Other" Health Care -- 20% member coinsurance after the preferred (per calendar year) deductible for services that are neither "preferred" nor "non-preferred". FAMILY PLANNING IN-NETWORK OUT-OF-NETWORK Infertility Treatment Member cost sharing is based on the type of service performed and the place of service where it is rendered Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services Not Covered Not Covered Advanced Reproductive Technology (ART) Not Covered Not Covered Vasectomy Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible. Tubal Ligation Covered 100%; deductible waived Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible. Voluntary Abortion Not Covered Not Covered PHARMACY IN-NETWORK OUT-OF-NETWORK Pharmacy Plan Type Open Formulary; with mid year changes Retail $10 copay for generic drugs, $40 copay for formulary brand-name drugs, and $60 copay for non-formulary brand-name drugs up to a 30 day supply at participating pharmacies. 50% of submitted cost after the applicable preferred copay


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:21 PM Page 5
Mail Order $20 copay for generic drugs, $80 copay for formulary brand-name drugs, and $120 copay for non-formulary brand-name drugs up to a 31-90 day supply from Aetna Rx Home Delivery®.
Not Applicable
Aetna Specialty CareRx First prescription fill at any retail drug facility. Subsequent fills must be through Aetna Specialty Pharmacy®. Choose Generics - If the member or the physician requests brand when generic is available, the member pays the applicable copay plus the difference between the generic price and the brand price. Plan Includes: Diabetic supplies and Contraceptive drugs and devices obtainable from a pharmacy. Oral and injectable fertility drugs included (physician charges for injections are not covered under RX, medical coverage is limited). Precert for growth hormones included. Expanded Precert included with 90 day Transition of Care. Formulary Generic FDA-approved Women's Contraceptives and certain over-the-counter preventive medications covered 100% in network. GENERAL PROVISIONS Dependents Eligibility Spouse, children from birth to age 26 regardless of student status. Pre-existing Conditions Exclusion On effective date: Waived After effective date: Waived

**We cover the cost of services based on whether doctors are "in network" or "out of network." We want to help you understand how much we pay for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this "out-of-network" care.

You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your health plan may pay some of that doctor's bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital.

When you choose out-of-network care, we limit the amount it will pay. This limit is called the "recognized" or "allowed" amount.

• For doctors and other professionals the amount is based on what Medicare pays for these services. The government sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks.

• For hospitals and other facilities, the amount is based on what Medicare pays for these services. The government sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks.

Your doctor sets his or her own rate to charge you. It may be higher -- sometimes much higher -- than what your plan "recognizes." Your doctor may bill you for the dollar amount that we don't "recognize." You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the "recognized charge" counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit our website.

You can avoid these extra costs by getting your care from Aetna's broad network of health care providers. Go to www.aetna.com and click on "Find a Doctor" on the left side of the page. If you are already a member, sign on to your Navigator member site.


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:21 PM Page 6

This applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles.

This way of paying out-of-network doctors and hospitals applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident), we will pay the bill as if you got care in network. You pay your plan's copayments, coinsurance and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance and deductibles.

Plans are provided by: Aetna Life Insurance Company. While this material is believed to be accurate as of the production date, it is subject to change.

Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered.

See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. You may be responsible for the health care provider's full charges for any non-covered services, including circumstances where you have exceeded a benefit limit contained in the plan. Providers are independent contractors and are not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services.

The following is a list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:21 PM Page 7

• All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents. • Cosmetic surgery, including breast reduction. • Custodial care. • Dental care and dental X-rays. • Donor egg retrieval. • Durable medical Equipment • Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial. • Hearing aids • Home births • Immunizations for travel or work, except where medically necessary or indicated. • Implantable drugs and certain injectable drugs including injectable infertility drugs. • Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents. • Long-term rehabilitation therapy. • Non-medically necessary services or supplies. • Orthotics except diabetic orthotics. • Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over-the-counter medications (except as provided in a hospital) and supplies. • Radial keratotomy or related procedures. • Reversal of sterilization. • Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling or prescription drugs. • Special duty nursing. • Therapy or rehabilitation other than those listed as covered. • Treatment of behavioral disorders. • Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions.

Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc., that operates through mail order. The charges that Aetna negotiates with Aetna Rx Home Delivery may be higher than the cost they pay for the drugs and the cost of the mail order pharmacy services they provide. For these purposes, the pharmacy's cost of purchasing drugs takes into account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors.

In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.

Translation of the material into another language may be available. Please call Member Services at 1-888-982-3862.

Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al 1-888-982-3862.

Plan features and availability may vary by location and group size.

For more information about Aetna plans, refer to www.aetna.com.


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:21 PM Page 8

© 2014 Aetna Inc.






Prepared: 09/25/2014 03:23 PM









PLAN DESIGN

Customer Name: The Romine Group

Proposed Effective Date: 01-01-2015

Policy Period: 12

Data Source ID: Q3188722 - 2 - All Employees/NC/250/4629MIPP#2148

Option: $3000 PPO Plan

Plan: PPO Plan

Location(s): Michigan

Specialty Networks Included: None Quoted

Organization Name: Aetna




The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:23 PM Page 1
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $3,000 Individual $6,000 Individual $6,000 Family $12,000 Family All covered expenses accumulate separately toward the preferred or non-preferred Deductible. Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost sharing for certain services, as indicated in the plan, are excluded from charges to meet the Deductible. Pharmacy expenses do not apply towards the Deductible. The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met by a combination of family members; however no single individual within the family will be subject to more than the individual Deductible amount. Member Coinsurance Covered 100% 20% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $3,000 Individual $11,000 Individual $6,000 Family $22,000 Family All covered expenses accumulate separately toward the preferred or non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Pharmacy expenses apply towards the Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, copays, and deductibles (except any penalty amounts) may be used to satisfy the Payment Limit. The family Payment Limit is a cumulative Payment Limit for all family members. The family Payment Limit can be met by a combination of family members; however no single individual within the family will be subject to more than the individual Payment Limit amount. Lifetime Maximum Unlimited except where otherwise indicated. Payment for Non-Preferred Care** Not Applicable Professional: 105% of Medicare Facility: 140% of Medicare Primary Care Physician Selection Not Applicable Not Applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $400 per occurrence. Referral Requirement None None PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK Routine Adult Physical Exams/ Immunizations Covered 100%; deductible waived 20%; after deductible 1 exam every 12 months for members age 22 to age 65; 1 exam every 12 months for adults age 65 and older. Routine Well Child Exams/Immunizations Covered 100%; deductible waived 20%; after deductible 7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12 months of life, 1 exam per year thereafter to age 22. Routine Gynecological Care Exams Covered 100%; deductible waived 20%; after deductible Recommended: One exam per calendar year. Includes routine tests and related lab fees. Routine Mammograms Covered 100%; deductible waived 20%; after deductible Recommended: One baseline mammogram for covered females age 35-39, one mammogram per calendar year for covered females age 40 and over. Women's Health Covered 100%; deductible waived 20%; after deductible Includes: Screening for gestational diabetes, HPV (Human- Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies and counseling.


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:23 PM Page 2
Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam Covered 100%; deductible waived 20%; after deductible Prostate-specific Antigen Test Covered 100%; deductible waived 20%; after deductible Colorectal Cancer Screening Covered under Routine Adult Exams Covered under Routine Adult Exams Recommended: For all members age 50 and over. Routine Eye Exams Covered 100%; deductible waived Not Covered 1 routine exam per 24 months. Routine Hearing Exams Not Covered Not Covered Routine Hearing Screening Covered 100%; deductible waived 20%; after deductible PHYSICIAN SERVICES IN-NETWORK OUT-OF-NETWORK Office Visits to non-Specialist $40 office visit copay; deductible waived 20%; after deductible Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits $40 office visit copay; deductible waived 20%; after deductible Pre-Natal Maternity Covered 100%; deductible waived Covered according to standard claim practice. E-visit to Non-Specialist Not Covered Not Covered An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through our authorized internet E-visit service vendor. E-visit to Specialist Not Covered Not Covered An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through our authorized internet E-visit service vendor. Walk-in Clinics $40 office visit copay; deductible waived 20%; after deductible Walk-in Clinics are network, free-standing health care facilities. They are an alternative to a physician's office visit for treatment of unscheduled, non-emergency illnesses and injuries and the administration of certain immunizations. It is not an alternative for emergency room services or the ongoing care provided by a physician. Neither an emergency room, nor the outpatient department of a hospital, shall be considered a Walk-in Clinic. Allergy Testing Member cost sharing is based on the type of service performed and the place of service where it is rendered; deductible waived Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Allergy Injections Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible DIAGNOSTIC PROCEDURES IN-NETWORK OUT-OF-NETWORK Diagnostic X-ray Covered 100%; after deductible 20%; after deductible If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Diagnostic Laboratory Covered 100%; after deductible 20%; after deductible If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Diagnostic Outpatient Complex Imaging Covered 100%; after deductible 20%; after deductible EMERGENCY MEDICAL CARE IN-NETWORK OUT-OF-NETWORK Urgent Care Provider $50 copay; deductible waived 20%; after deductible Non-Urgent Use of Urgent Care Provider Not Covered Not Covered


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

Prepared: 09/25/2014 03:23 PM Page 3
Emergency Room $150 copay; deductible waived Same as preferred care Non-Emergency Care in an Emergency Room Not Covered Not Covered Emergency Use of Ambulance $100 copay; after deductible $100 copay; after deductible Non-Emergency Use of Ambulance Not Covered Not Covered HOSPITAL CARE IN-NETWORK OUT-OF-NETWORK Inpatient Coverage Covered 100%; after deductible 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Inpatient Maternity Coverage (includes delivery and postpartum care) Covered 100%; after deductible 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Hospital Expenses Covered 100%; after deductible 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Outpatient Surgery Covered 100% 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Outpatient Surgery - Freestanding Facility Covered 100%; after deductible 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. MENTAL HEALTH SERVICES IN-NETWORK OUT-OF-NETWORK Inpatient Covered 100%; after deductible 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient $40 copay; deductible waived 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. ALCOHOL/DRUG ABUSE SERVICES IN-NETWORK OUT-OF-NETWORK Inpatient Covered 100%; after deductible 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Residential Treatment Facility Covered 100%; after deductible 20%; after deductible Treatment Facility Covered 100%; after deductible 20%; after deductible Outpatient $40 copay; deductible waived 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. OTHER SERVICES IN-NETWORK OUT-OF-NETWORK Convalescent Facility Covered 100%; after deductible 20%; after deductible Limited to 60 days per calendar year. The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Home Health Care Covered 100%; after deductible 20%; after deductible Limited to 60 visits per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient Covered 100%; after deductible 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Hospice Care - Outpatient Covered 100%; after deductible 20%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Private Duty Nursing - Outpatient Not Covered Not Covered Outpatient Short-Term Rehabilitation $40 copay; deductible waived 20%; after deductible Includes Speech, Physical, and Occupational Therapy, limited to 60 visits per calendar year. Spinal Manipulation Therapy $40 copay; deductible waived 20%; after deductible Limited to 20 visits per calendar year.


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

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Autism Behavioral Therapy $40 copay; deductible waived 20%; after deductible Covered same as any other Outpatient Mental Health benefit Autism Applied Behavior Analysis $40 copay; deductible waived 20%; after deductible Covered same as any other Outpatient Mental Health benefit with no age or visit limitations. Autism Physical Therapy $40 copay; deductible waived 20%; after deductible Visits combined with Short Term Rehabilitation. Autism Occupational Therapy $40 copay; deductible waived 20%; after deductible Visits combined with Short Term Rehabilitation. Autism Speech Therapy $40 copay; deductible waived 20%; after deductible Visits combined with Short Term Rehabilitation. Durable Medical Equipment Covered 100%; after deductible 20%; after deductible Diabetic Supplies -- (if not covered under Pharmacy benefit) Covered same as any other medical expense. Covered same as any other medical expense. Generic FDA-approved Women's Contraceptives Covered 100%; deductible waived Not Covered Contraceptive drugs and devices not obtainable at a pharmacy Covered 100%; deductible waived Covered same as any other medical expense. Transplants Covered 100%; after deductible 20%; after deductible Preferred coverage is provided at an IOE contracted facility only. Non-Preferred coverage is provided at a Non-IOE facility. Bariatric Surgery Not Covered Not Covered The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. "Other" Health Care -- 20% member coinsurance after the preferred (per calendar year) deductible for services that are neither "preferred" nor "non-preferred". FAMILY PLANNING IN-NETWORK OUT-OF-NETWORK Infertility Treatment Member cost sharing is based on the type of service performed and the place of service where it is rendered Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services Not Covered Not Covered Advanced Reproductive Technology (ART) Not Covered Not Covered Vasectomy Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible. Tubal Ligation Covered 100%; deductible waived Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible. Voluntary Abortion Not Covered Not Covered PHARMACY IN-NETWORK OUT-OF-NETWORK Pharmacy Plan Type Open Formulary; with mid year changes Retail $15 copay for generic drugs, $35 copay for formulary brand-name drugs, and $60 copay for non-formulary brand-name drugs up to a 30 day supply at participating pharmacies. 20% of submitted cost after the applicable preferred copay


The Romine Group Proposed Effective Date: 01-01-2015 Open Choice® (PPO) - Michigan
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Mail Order $30 copay for generic drugs, $70 copay for formulary brand-name drugs, and $120 copay for non-formulary brand-name drugs up to a 31-90 day supply from Aetna Rx Home Delivery®.
Not Applicable
Aetna Specialty CareRx First prescription fill at any retail drug facility. Subsequent fills must be through Aetna Specialty Pharmacy®. Choose Generics - If the member or the physician requests brand when generic is available, the member pays the applicable copay plus the difference between the generic price and the brand price. Plan Includes: Diabetic supplies and Contraceptive drugs and devices obtainable from a pharmacy. Oral and injectable fertility drugs included (physician charges for injections are not covered under RX, medical coverage is limited). Precert for growth hormones included. Expanded Precert included with 90 day Transition of Care. Formulary Generic FDA-approved Women's Contraceptives and certain over-the-counter preventive medications covered 100% in network. GENERAL PROVISIONS Dependents Eligibility Spouse, children from birth to age 26 regardless of student status. Pre-existing Conditions Exclusion On effective date: Waived After effective date: Waived

**We cover the cost of services based on whether doctors are "in network" or "out of network." We want to help you understand how much we pay for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this "out-of-network" care.

You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your health plan may pay some of that doctor's bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital.

When you choose out-of-network care, we limit the amount it will pay. This limit is called the "recognized" or "allowed" amount.

• For doctors and other professionals the amount is based on what Medicare pays for these services. The government sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks.

• For hospitals and other facilities, the amount is based on what Medicare pays for these services. The government sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks.

Your doctor sets his or her own rate to charge you. It may be higher -- sometimes much higher -- than what your plan "recognizes." Your doctor may bill you for the dollar amount that we don't "recognize." You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the "recognized charge" counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit our website.

You can avoid these extra costs by getting your care from Aetna's broad network of health care providers. Go to www.aetna.com and click on "Find a Doctor" on the left side of the page. If you are already a member, sign on to your Navigator member site.


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This applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles.

This way of paying out-of-network doctors and hospitals applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident), we will pay the bill as if you got care in network. You pay your plan's copayments, coinsurance and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance and deductibles.

Plans are provided by: Aetna Life Insurance Company. While this material is believed to be accurate as of the production date, it is subject to change.

Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered.

See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. You may be responsible for the health care provider's full charges for any non-covered services, including circumstances where you have exceeded a benefit limit contained in the plan. Providers are independent contractors and are not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services.

The following is a list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.


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• All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents. • Cosmetic surgery, including breast reduction. • Custodial care. • Dental care and dental X-rays. • Donor egg retrieval. • Durable medical Equipment • Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial. • Hearing aids • Home births • Immunizations for travel or work, except where medically necessary or indicated. • Implantable drugs and certain injectable drugs including injectable infertility drugs. • Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents. • Long-term rehabilitation therapy. • Non-medically necessary services or supplies. • Orthotics except diabetic orthotics. • Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over-the-counter medications (except as provided in a hospital) and supplies. • Radial keratotomy or related procedures. • Reversal of sterilization. • Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling or prescription drugs. • Special duty nursing. • Therapy or rehabilitation other than those listed as covered. • Treatment of behavioral disorders. • Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions.

Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc., that operates through mail order. The charges that Aetna negotiates with Aetna Rx Home Delivery may be higher than the cost they pay for the drugs and the cost of the mail order pharmacy services they provide. For these purposes, the pharmacy's cost of purchasing drugs takes into account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors.

In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.

Translation of the material into another language may be available. Please call Member Services at 1-888-982-3862.

Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al 1-888-982-3862.

Plan features and availability may vary by location and group size.

For more information about Aetna plans, refer to www.aetna.com.


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© 2014 Aetna Inc.

version 2-14 Date Printed: 10-14-2014
Effective Date: 01-01-2015 Plan 19a External Plan ID 9849662419 Line Value 366 12 12 12 Exam Aetna Vision Network
Routine/Comprehensive Eye Exam $10 Copay $25 Reimbursement Standard Contact Lens Fit/Follow-up Member pays discounted fee of $40 Not Covered Premium Contact Lens Fit/Follow-up Member pays 90% of retail Not Covered
Single vision lenses $10 Copay $20 Reimbursement Bifocal vision lenses $10 Copay $40 Reimbursement Trifocal vision lenses $10 Copay $65 Reimbursement Lenticular vision lenses $10 Copay $65 Reimbursement Standard Progressive vision lenses $75 Copay $40 Reimbursement
Premium Progressive vision lenses1
20% Discount off retail minus $120 plan allowance plus $75 Copay = member out-of-pocket
$40 Reimbursement
UV treatment Member pays discounted fee of $15 Not Covered Tint (Solid and Gradient) Member pays discounted fee of $15 Not Covered Standard plastic scratch coating $0 Copay $15 Reimbursement Standard polycarbonate lenses - Adult Member pays discounted fee of $40 Not Covered Standard polycarbonate lenses - Children to age 19 $0 Copay $35 Reimbursement Standard anti-reflective coating Member pays discounted fee of $45 Not Covered Polarized Member pays 80% of retail Not Covered
Conventional contact lenses $130 Allowance** Additional 15% off balance over allowance
$90 Reimbursement Disposable contact lenses $130 Allowance $90 Reimbursement Medically necessary contact lenses $0 Copay $200 Reimbursement
Any Frame available, including frames for prescription sunglasses
$130 allowance Additional 20% off balance over allowance
$65 Reimbursement
Additional pairs of eyeglasses or prescription sunglasses. Discount applies to purchases made after the plan allowances have been exhausted.
Up to a 40% Discount No Discount
Non-covered items such as cleaning cloths and contact lens solution2 20% Discount No Discount Lasik Laser vision correction or PRK from U.S. Laser Network3 only. Call 1-800-422-6600 15% discount off retail or 5% discount off the promotional price No Discount Retinal Imaging4 Member pays a discounted fee up to $39 No Discount
Replacement contact lenses
Receive significant savings after your lens benefit has been exhausted on replacement contacts by ordering online. Visit www.aetnavision.com for details
No Discount
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Aetna VisionSM Preferred visit www.aetnavision.com
In Network Out of Network* Summary of Benefits for The Romine Group
Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses
Use your Exam coverage once every rolling 12 months
Discounts
Eyeglass Lenses /Lens options
Contact Lenses
Use your Frame coverage once every rolling 12 months
Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses
Frames
Discounts cannot be combined with any other discounts or promotional offers and may not be available on all brands.
version 2-14 Date Printed: 10-14-2014
This material is for information only, and is not an offer or invitation to contract. Extraterritorial state requirements may apply to members residing in specific States. If your plan covers members in other states, impacts to your plan of benefits and rates adjustments (if any) will be evaluated and communicated to you at the point of sale.
**Allowances are one-time use benefits. No remaining balances may be used. The plan does not provide a declining balance benefit. 1Premium progressives and premium anti-reflective Brand designations are subject to annual review and change based on market conditions. Ask your eye care provider for more information. 2Non covered discounts may not be available in all states. 3Lasik or PRK from the US Laser Network, owned and operated by LCA Vision. 4Retinal Imaging available at participating locations. Contact your eyecare provider to verify if available. Vision insurance plans are underwritten by Aetna Life Insurance Company (Aetna). Certain claims administration services are provided by First American Administrators, Inc. and certain network administration services are provided through EyeMed Vision Care (“EyeMed”), LLC. Providers participating in the Aetna Vision network are contracted through EyeMed Vision Care, LLC. EyeMed and Aetna are independent contractors and not employees or agents of each other. Participating vision providers are credentialed by and subject to the credentialing requirements of EyeMed. Aetna does not provide medical/vision care or treatment and is not responsible for outcomes. Aetna does not guarantee access to vision care services or access to specific vision care providers and provider network composition is subject to change without notice.
*You can choose to receive care outside the network. Simply pay for the services up front and then submit a claim form to receive an amount up to the out of network reimbursement amounts listed above. Reimbursement will not exceed the providers actual charge. Claim forms can be found at www.aetnavision.com or by calling customer service Mon-Sun @ 877-9-SEE-AETNA. Submit completed claim form with receipts to Aetna, PO Box 8504 Mason, OH 45040-7111. Vision insurance plans contain exclusions and limitations. Not all vision services are covered. See your plan booklet for details. Partial list of Exclusions and Limitations
For Employees of The Romine Group ELIGIBILITY - ALL ELIGIBLE EMPLOYEES Eligibility Requirement You must be actively at work (able to perform all normal duties of your job) to be eligible for coverage. Dependent Eligibility Requirement To be eligible for coverage, your dependents must be able to perform normal activities and not be confined (at home, in a hospital, or in any other care facility). Minimum Work Hours You must be working a minimum of30hours perweek to be eligible for coverage. Coverage Payment Your employer pays 100% of the premium for this coverage. LATE ENTRANTS WAITING PERIODS Type A Waived Type B 12 Months Type C 12 Months Orthodontia 12 Months CALENDAR YEAR DEDUCTIBLES AND MAXIMUMS PARTICIPATING PROVIDERS2 NON-PARTICIPATING PROVIDERS2* Type A Deductible Waived Waived Type B & C Deductible §Each Insured Person $0 $0 §Family 3 times Individual 3 times Individual Maximum(s) (For Each Insured Person) §Type A, B & C Combined $1,000 $1,000 §Orthodontia $1,000 (Lifetime1) $1,000 (Lifetime1) 1Reference to "Lifetime" indicates an amount that applies or is available only once while insured under this policy. 2The same expense(s) may be used to satisfy the deductibles for participating and non-participating providers. COVERED SERVICES PARTICIPATING NON-PARTICIPATING* Type A Services 100% 50% §Examination(s)/Evaluation(s) §Bitewing X-ray(s) §Other X-ray(s) §Fluoride Treatment(s) §Cleaning(s) (Prophylaxis) §Sealant(s) §Space Maintainer(s) (Including Recementation) §Emergency Treatment §Brush Biopsy/Cancer Screening Type B Services 75% 50% §Periodontal Maintenance (Following Active Periodontal Treatment) §Filling(s) §Stainless Steel Crowns §Extraction(s) §Oral Surgery §General Anesthesia or Intravenous (I.V.) Sedation §Endodontics §Periodontics §Repair of Removable Dentures §Adjustments, Tissue Conditioning, Rebasing or Relining of Removable Dentures §Repair and Re-Cementation of Bridges §Crowns, Inlays, Onlays §Repair and Re-cementation of Cast Crowns/Inlays/Onlays
COVERED SERVICES (CONTINUED) PARTICIPATING NON-PARTICIPATING* Type C Services 50% 50% §Full or Partial Removable Dentures §Bridgework (Fixed Dentures) §Endosteal Implant(s) Orthodontia §Available for dependent children 50% 40% The plan pays the percentage shown after the deductible is satisfied, up to the maximum. Additional information about the benefits and covered services of this plan will be included in the certificate booklet, which you will receive after enrolling for this coverage. Please contact your employer or benefits administrator if you have questions prior to enrolling. This plan provides different coverage levels for participating and non-participating providers. By using a participating provider, plan members will save more through the predetermined fee arrangement and better benefit coverage. *The Maximum Allowance for non-participating providers is based on the 90th percentile of prevailing fee data for the geographical area. Charges that exceed the Maximum Allowance (as defined in the certificate booklet) for any covered dental service are not considered. LIMITATIONS AND EXCLUSIONS Information about the limitations and exceptions for this plan will be included in the certificate booklet, which you will receive after enrolling for this coverage. Please contact your employer or benefits administrator if you have any questions prior to enrolling. This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificate booklet for a full explanation of the plan's benefits, exclusions and limitations. Should there be any discrepancy between the certificate booklet and this outline, the certificate booklet will prevail. Dental insurance is underwritten by Mutual of Omaha Insurance Company or United of Omaha Life Insurance Company. Mutual of Omaha Insurance Company is licensed in all 50 states. United of Omaha Life Insurance Company is licensed in all states but New York. In New York, Mutual of Omaha Insurance Company underwrites the plan. Policy Form Number 7000GM-MU-EZ 2001.