AETNA ADVANTAGE PLANS FOR INDIVIDUALS,
FAMILIES AND THE SELF-EMPLOYED
NEW PROVISIONS EFFECTIVE SEPTEMBER 23, 2010
This information is an addendum to the printed materials you received.
©2010 Aetna Inc.
13.03.536.1 (7/10)
The federal health care
reform legislation, known
as the Patient Protection
and Affordable Care Act,
was signed into law
on March 23, 2010 by
President Obama.
The following health care
reform changes are effective
on September 23, 2010:
Allow dependent coverage up
to age 26
Remove lifetime benefi t limits –
based on dollar amounts
Take away cost-sharing obligations
for preventive services (In network)
Eliminate pre-existing condition
exclusions for dependent children
(under 19 years of age)
Please note that some previously
printed materials do not refl ect these
changes. However, the new provisions
are in effect for plans with an effective
date on or after September 23, 2010,
and your Aetna Advantage Plan does
comply with the new federal health
care reform legislation.
If you have any questions, please talk to
your broker or call 1-800-MY-HEALTH.
Please note that in addition to health care reform changes, coverage for children only may
no longer be available in your state. Also, all plans described in the printed material you
received may not currently be available in your state.
Aetna Advantage Plans for Individuals, Families and the Self-Employed are underwritten by Aetna
Life Insurance Company (Aetna) directly and/or through an out-of-state blanket trust or Aetna
Health Inc. In some states, individuals may qualify as a business group of one and may be eligible
for guaranteed issue, small group health plans. These plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
AA.02.305.1-AK (4/10) B
Take charge
of your health.
Were here to help.
AETNA ADVANTAGE PLANS FOR
INDIVIDUALS, FAMILIES AND THE
SELF-EMPLOYED IN ALASKA
Aetna Advantage
plan choices
Aetna Advantage Plans for Individuals, Families and the
Self-Employed are underwritten by Aetna Life Insurance
Company (Aetna) directly and/or through an out-of-state
blanket trust. In some states, individuals may qualify as a
business group of one and may be eligible for guaranteed
issue, small group health plans. These plans are medically
underwritten and you may be declined coverage in accordance
with your health condition.
1
Our health insurance plans are designed to
offer you quality coverage at an excellent
value. Coverage can include prescription drugs,
doctor visits, hospitalization and preventive
care services.
Generally speaking, the lower your “premiums,” or
monthly payments, the higher your “deductible,” which is
the amount you pay out of pocket before the plan begins
paying for expenses.
You’ll pay less by usingin-network doctors, hospitals,
pharmacies and other health care providers who
participate in Aetna’s nationwide network than by using
“out-of-network” doctors.
Visit www.planforyourhealth.com for an in-depth list
of terms in this brochure and what they mean.
About HSAs
Many of our high-deductible plans are Health Savings
Account (HSA) Compatible, offering you lower premiums
and tax advantaged savings. An HSA is a personal
account that lets you pay for qualified medical expenses
with tax advantaged funds. You or an eligible family
member make contributions to your HSA tax-free, and
those dollars earn interest tax-free. Then, when you make
withdrawals from your account to pay for qualified health
care expenses, they’re tax-free, too.
It’s easy to establish a Health Savings Account…
Simply enroll in an Aetna HSA Compatible High Deductible
Health Plan and you will automatically have an HSA opened
through Bank of America. You will also receive a debit card
and a welcome package with additional information to get
you started.
If you do not wish to set up an HSA, you can opt out
by calling Bank of America or the account will be
automatically canceled after 90 days if the debit card is not
activated or if you do not enroll online.
Why choose an Aetna HealthFund HSA?
n
No set-up fees
n
No monthly administration fee
n
No withdrawal forms required
n
Convenient access to HSA funds via debit card or online
n
Track HSA activity online
Is your doctor in the Aetna network?
Which local physicians, hospitals, pharmacies and eyewear
providers participate in the nationwide Aetna Advantage
Plan network? Visit www.aetna.com/docfind/custom/
advplans. Or call 1-800-694-3258 and ask for a directory
of providers.
Get more from your Aetna plan
Cover just your children
Aetna Advantage Plans are also available for children only,
which means you can enroll your child even if no other
family member enrolls. Coverage includes immunizations,
well-child visits, emergency room and dental preventive
services (if a dental plan is selected).
Note: when an HSA Compatible plan is selected for child only
enrollment, an HSA account is not available for the child.
Add Dental PPO Max
With the Aetna Advantage Dental PPO Max insurance
plan, you can obtain services from either a participating or
non-participating dentist. Participating dentists have agreed
to provide services at a negotiated rate for both covered
services, as well as non-covered services such as cosmetic
tooth whitening and orthodontic care, so you generally
pay less out-of-pocket. You also have the flexibility to visit a
dentist who does not participate in Aetna’s network, though
you will not have access to negotiated fees. Dental coverage
is offered only if medical coverage is obtained.
32
Plan Details
3)
1)
2)
PPO plan options
Robust coverage and lower monthly payments
balanced with a deductible…where you dont
want to pay a lot for frequent doctor visits
Featuring:
n
Health insurance coverage with lower monthly premiums
and varying deductible levels
PPO High Deductible plan options
Lower premium costs…and an HSA-compatible
plan that offers tax advantaged savings
Featuring:
n
0% coinsurance in network after your deductible is met
n
Lower monthly premiums, higher annual deductibles
(at least $3,000 for individuals and $6,000 for families)
n
Can be paired with a tax-advantaged Health
Savings Account (HSA)
PPO Value plan options
Affordability a balance of lower monthly
premiums and quality coverage…where you want
to cap the amount you’ll spend on total medical
expenses each year
Featuring:
n
Lower monthly premiums (that’s the “Value” part)
n
No deductible for generic prescription drugs
Preventive and Hospital Care
plan options
Affordability is one of your top priorities and
you use only basic health care services…and
want to keep your monthly premiums lower
Featuring:
n
Health insurance coverage with lower monthly
premiums and varying deductible levels
PPO 7500 with Unlimited
Primary Care Visits plus Dental
plan option
Medical and dental coverage; and vision
discounts bundled together...at a reasonable cost
Featuring:
n
One monthly premium for medical and dental
coverage; and vision discounts
n
Lower monthly premiums, higher annual deductibles
(at least $7,500 for individuals and $15,000 for families)
n
100% coverage for diagnostic and preventive dental
services from a preferred provider
4)
5)
Your rates will depend on the area in
which your county is located.
For more information or a quote on what your
rate would be, call your 1-800-My Health.
Area 1 Counties
Aleutians East
Aleutians West
Anchorage
Bethel
Bristol Bay
Denali
Dillingham
Haines
Juneau
Kenai Peninsula
Ketchikan Gateway
Kodiak Island
Lake and Peninsula
Matanuska Susitna
Nome
North Slope
Northwest Arctic
Prince Wales Ketchikan
Sitka
Skagway Hoonah Angoon
Southeast Fairbanks
Valdez Cordova
Wade Hampton
Wrangell Petersburg
Yakutat
Area 2 Counties
Fairbanks North Star Yukon Koyukuk
5
PLUS ... THESE BENEFITS ARE
INCLUDED WITH MOST OF
OUR PLANS.
n
No claim forms to fill out when you visit
a network provider
n
No referrals required to see a specialist*
n
No waiting period for routine physical exams
n
100% annual routine GYN exam coverage —
no waiting period, no dollar maximum and
no copay or deductible when you visit a
network provider
n
Coverage for prescription drugs*
n
Coverage for routine physicals including lab work
and X-rays
n
100% coverage for in-network childhood
immunizations
* These benefits are not applicable to Preventive and Hospital Care plans
AETNA’S ALASKA
RATINGS AREAS*
* All products not available in all counties. Please refer to the county
in which you reside for the available product.
4
76
1)
* Maximum applies to combined in and out-of-network benefits.
** Copay is billed separately and not due at time of service. Copay does not
count towards coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility care is the recognized charge for a
service or supply that is equal to or greater than the 80th percentile of the
provider charge data from the Ingenix Incorporated Prevailing HealthCare
Charges System (PHCS).
PPO 2500
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$2,500
$5,000
$5,000
$10,000
Coinsurance
(Member’s responsibility)
20%
after deductible
20%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$2,500
$5,000
$5,000
$10,000
Out-of-Pocket Maximum
Individual
Family
$5,000
$10,000
$10,000
$20,000
Includes deductible
Lifetime Maximum* per insured
$5,000,000
Non-specialist Office Visit
Unlimited Visits
General Physician, Family Practitioner,
Pediatrican or Internist
$30 copay
deductible waived
$30 copay
deductible waived
Specialist Visit
Unlimited Visits
$40 copay
deductible waived
$40 copay
deductible waived
Hospital Admission
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
$30 copay
deductible waived
$30 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
20%
after deductible
20%
after deductible
Skilled Nursing In lieu of Hospital
30 days per calendar year*
20%
after deductible
20%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
20%
after deductible
20%
after deductible
Aetna will pay up to $25 per visit max.*
Home Health Care
In lieu of Hospital
30 visits per calendar year*
20%
after deductible
20%
after deductible
Durable Medical Equipment
Aetna will pay $2,000 per calendar year*
20%
after deductible
20%
after deductible
PHARMACY
Pharmacy Deductible
per Individual
$500 $500
Does not apply to generic
Generic
Oral Contraceptives Included
$15 copay
deductible waived
$15 copay
deductible waived
Preferred Brand Name
Oral Contraceptives Included
$25 copay
after deductible
$25 copay
after deductible
Non-Preferred Brand
Oral Contraceptives Included
$40 copay
after deductible
$40 copay
after deductible
Self Injectables
20%
after deductible
20%
after deductible
Calendar Year Maximum
per individual*
Unlimited Unlimited
PPO 5000
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$5,000
$10,000
$10,000
$20,000
Coinsurance
(Member’s responsibility)
20%
after deductible
20%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$2,500
$5,000
$2,500
$5,000
Out-of-Pocket Maximum
Individual
Family
$7,500
$15,000
$12,500
$25,000
Includes deductible
Lifetime Maximum* per insured
$5,000,000
Non-specialist Office Visit
Unlimited Visits
General Physician, Family Practitioner,
Pediatrican or Internist
$40 copay
deductible waived
$40 copay
deductible waived
Specialist Visit
Unlimited Visits
$50 copay
deductible waived
$50 copay
deductible waived
Hospital Admission
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health
Routine Physical
Aetna will pay up to $200 per exam*
$40 copay
deductible waived
$40 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
20%
after deductible
20%
after deductible
Skilled Nursing In lieu of Hospital
30 days per calendar year*
20%
after deductible
20%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
20%
after deductible
20%
after deductible
Aetna will pay up to $25 per visit max.*
Home Health Care
In lieu of Hospital
30 visits per calendar year*
20%
after deductible
20%
after deductible
Durable Medical Equipment
Aetna will pay $2,000 per calendar year*
20%
after deductible
20%
after deductible
PHARMACY
Pharmacy Deductible
per Individual
$500 $500
Does not apply to generic
Generic
Oral Contraceptives Included
$15 copay
deductible waived
$15 copay
deductible waived
Preferred Brand Name
Oral Contraceptives Included
$25 copay
after deductible
$25 copay
after deductible
Non-Preferred Brand
Oral Contraceptives Included
$40 copay
after deductible
$40 copay
after deductible
Self Injectables
20%
after deductible
20%
after deductible
Calendar Year Maximum
per individual*
Unlimited Unlimited
98
* Maximum applies to combined in and out-of-network benefits.
** Copay is billed separately and not due at time of service. Copay does not
count towards coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility care is the recognized charge for a
service or supply that is equal to or greater than the 80th percentile of the
provider charge data from the Ingenix Incorporated Prevailing HealthCare
Charges System (PHCS).
PPO High Deductible 3000
(HSA Compatible)
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$3,000
$6,000
$6,000
$12,000
Coinsurance
(Member’s responsibility)
0%
after deductible
0%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$0
$0
$6,500
$13,000
Out-of-Pocket Maximum
Individual
Family
$3,000
$6,000
$12,500
$25,000
Includes deductible
Lifetime Maximum* per insured
$5,000,000
Non-specialist Office Visit
Unlimited Visits
General Physician,
Family Practitioner,
Pediatrican or Internist
0%
after deductible
0%
after deductible
Specialist Visit
Unlimited Visits
0%
after deductible
0%
after deductible
Hospital Admission
0%
after deductible
50%
after deductible
Outpatient Surgery
0%
after deductible
50%
after deductible
Urgent Care Facility
0%
after deductible
50%
after deductible
Emergency Room
$0 copay after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
$20 copay
deductible waived
$20 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
0%
after deductible
0%
after deductible
Skilled Nursing In lieu of Hospital
30 days per calendar year*
0%
after deductible
0%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
0%
after deductible
0%
after deductible
Aetna will pay up to $25 per visit max.*
Home Health Care
In lieu of Hospital
30 visits per calendar year*
0%
after deductible
0%
after deductible
Durable Medical Equipment
Aetna will pay $2,000 per calendar year*
0%
after deductible
0%
after deductible
PHARMACY
Pharmacy Deductible
per Individual
Integrated Medical/
Rx deductible
Integrated Medical/
Rx deductible
Generic
Oral Contraceptives Included
0% after Medical/
Rx Deductible
0% after Medical/
Rx Deductible
Preferred Brand Name
Oral Contraceptives Included
0% after Medical/
Rx Deductible
0% after Medical/
Rx Deductible
Non-Preferred Brand
Oral Contraceptives Included
0% after Medical/
Rx Deductible
0% after Medical/
Rx Deductible
Self Injectables
0% after Medical/
Rx Deductible
0% after Medical/
Rx Deductible
Calendar Year Maximum
per individual*
Unlimited Unlimited
PPO High Deductible 5000
(HSA Compatible)
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$5,000
$10,000
$10,000
$20,000
Coinsurance
(Member’s responsibility)
0%
after deductible
0%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$0
$0
$2,500
$5,000
Out-of-Pocket Maximum
Individual
Family
$5,000
$10,000
$12,500
$25,000
Includes deductible
Lifetime Maximum* per insured
$5,000,000
Non-specialist Office Visit
Unlimited Visits
General Physician,
Family Practitioner,
Pediatrican or Internist
0%
after deductible
0%
after deductible
Specialist Visit
Unlimited Visits
0%
after deductible
0%
after deductible
Hospital Admission
0%
after deductible
50%
after deductible
Outpatient Surgery
0%
after deductible
50%
after deductible
Urgent Care Facility
0%
after deductible
50%
after deductible
Emergency Room
$0 copay after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
$25 copay
deductible waived
$25 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
0%
after deductible
0%
after deductible
Skilled Nursing In lieu of Hospital
30 days per calendar year*
0%
after deductible
0%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
0%
after deductible
0%
after deductible
Aetna will pay up to $25 per visit max.*
Home Health Care
In lieu of Hospital
30 visits per calendar year*
0%
after deductible
0%
after deductible
Durable Medical Equipment
Aetna will pay $2,000 per calendar year*
0%
after deductible
0%
after deductible
PHARMACY
Pharmacy Deductible
per Individual
Integrated Medical/
Rx deductible
Integrated Medical/
Rx deductible
Generic
Oral Contraceptives Included
0% after Medical/
Rx Deductible
0% after Medical/
Rx Deductible
Preferred Brand Name
Oral Contraceptives Included
0% after Medical/
Rx Deductible
0% after Medical/
Rx Deductible
Non-Preferred Brand
Oral Contraceptives Included
0% after Medical/
Rx Deductible
0% after Medical/
Rx Deductible
Self Injectables
0% after Medical/
Rx Deductible
0% after Medical/
Rx Deductible
Calendar Year Maximum
per individual*
Unlimited Unlimited
2)
1110
* Maximum applies to combined in and out-of-network benefits.
** Copay is billed separately and not due at time of service. Copay does not
count towards coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility care is the recognized charge for a
service or supply that is equal to or greater than the 80th percentile of the
provider charge data from the Ingenix Incorporated Prevailing HealthCare
Charges System (PHCS).
PPO Value 1500
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$1,500
$3,000
$3,000
$6,000
Coinsurance
(Member’s responsibility)
30%
after deductible
30%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$1,500
$3,000
$4,500
$9,000
Out-of-Pocket Maximum
Individual
Family
$3,000
$6,000
$7,500
$15,000
Includes deductible
Lifetime Maximum* per insured
$3,000,000
Non-specialist Office Visit
Unlimited Visits
General Physician,
Family Practitioner,
Pediatrican or Internist
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Specialist Visit
Unlimited Visits
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Hospital Admission
30%
after deductible
50%
after deductible
Outpatient Surgery
30%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
30% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
$50 copay
deductible waived
$50 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
30%
after deductible
30%
after deductible
Skilled Nursing In lieu of Hospital
30 days per calendar year*
30%
after deductible
30%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
30%
after deductible
30%
after deductible
Aetna will pay up to $25 per visit max.*
Home Health Care
In lieu of Hospital
30 visits per calendar year*
30%
after deductible
30%
after deductible
Durable Medical Equipment
Aetna will pay $2,000 per calendar year*
30%
after deductible
30%
after deductible
PHARMACY
Pharmacy Deductible
per Individual
Not Applicable Not Applicable
Generic
Oral Contraceptives Included
$20 copay $20 copay
Preferred Brand Name
Oral Contraceptives Included
Not covered Not covered
Non-Preferred Brand
Oral Contraceptives Included
Not covered Not covered
Self Injectables
Not covered Not covered
Calendar Year Maximum
per individual*
$5,000 $5,000
PPO Value 2500
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$2,500
$5,000
$5,000
$10,000
Coinsurance
(Member’s responsibility)
30%
after deductible
30%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$2,500
$5,000
$5,000
$10,000
Out-of-Pocket Maximum
Individual
Family
$5,000
$10,000
$10.000
$20,000
Includes deductible
Lifetime Maximum* per insured
$3,000,000
Non-specialist Office Visit
Unlimited Visits
General Physician,
Family Practitioner,
Pediatrican or Internist
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Specialist Visit
Unlimited Visits
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Hospital Admission
30%
after deductible
50%
after deductible
Outpatient Surgery
30%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
30% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
$50 copay
deductible waived
$50 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
30%
after deductible
30%
after deductible
Skilled Nursing In lieu of Hospital
30 days per calendar year*
30%
after deductible
30%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
30%
after deductible
30%
after deductible
Aetna will pay up to $25 per visit max.*
Home Health Care
In lieu of Hospital
30 visits per calendar year*
30%
after deductible
30%
after deductible
Durable Medical Equipment
Aetna will pay $2,000 per calendar year*
30%
after deductible
30%
after deductible
PHARMACY
Pharmacy Deductible
per Individual
Not Applicable Not Applicable
Generic
Oral Contraceptives Included
$20 copay $20 copay
Preferred Brand Name
Oral Contraceptives Included
Not covered Not covered
Non-Preferred Brand
Oral Contraceptives Included
Not covered Not covered
Self Injectables
Not covered Not covered
Calendar Year Maximum
per individual*
$5,000 $5,000
3)
1312
4)
PPO Value 5000
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$5,000
$10,000
$10.000
$20,000
Coinsurance
(Member’s responsibility)
30%
after deductible
30%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$5,000
$10,000
$2,500
$5,000
Out-of-Pocket Maximum
Individual
Family
$10.000
$20,000
$12,500
$25,000
Includes deductible
Lifetime Maximum* per insured
$3,000,000
Non-specialist Office Visit
Unlimited Visits
General Physician, Family Practitioner,
Pediatrican or Internist
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Specialist Visit
Unlimited Visits
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Visits 1-2 $30 copay
deductible waived;
thereafter 30%
coinsurance after
deductible
Hospital Admission
30%
after deductible
50%
after deductible
Outpatient Surgery
30%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
30% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
$50 copay
deductible waived
$50 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
30%
after deductible
30%
after deductible
Skilled Nursing In lieu of Hospital
30 days per calendar year*
30%
after deductible
30%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
30%
after deductible
30%
after deductible
Aetna will pay up to $25 per visit max.*
Home Health Care
In lieu of Hospital
30 visits per calendar year*
30%
after deductible
30%
after deductible
Durable Medical Equipment
Aetna will pay $2,000 per calendar year*
30%
after deductible
30%
after deductible
PHARMACY
Pharmacy Deductible
per Individual
Not Applicable Not Applicable
Generic
Oral Contraceptives Included
$20 copay $20 copay
Preferred Brand Name
Oral Contraceptives Included
Not covered Not covered
Non-Preferred Brand
Oral Contraceptives Included
Not covered Not covered
Self Injectables
Not covered Not covered
Calendar Year Maximum
per individual*
$5,000 $5,000
* Maximum applies to combined in and out-of-network benefits.
** Copay is billed separately and not due at time of service. Copay does not
count towards coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility care is the recognized charge for a service
or supply that is equal to or greater than the 80th percentile of the provider
charge data from the Ingenix Incorporated Prevailing HealthCare Charges
System (PHCS).
++ Coverage will be provided for care and treatment of diabetes; this includes
coverage for equipment and supplies used exclusively with diabetes
management and outpatient self-management training.
Preventive and Hospital
Care 1250
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$1,250
$2,500
$2,500
$5,000
Coinsurance
(Members responsibility)
20%
after deductible
20%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$2,500
$5,000
$5,000
$10,000
Out-of-Pocket Maximum
Individual
Family
$3,750
$7,500
$7,500
$15,000
Includes deductible
Lifetime Maximum* per insured
$5,000,000
Non-Specialist Office Visit
General Physician, Family Practitioner,
Pediatrician or Internist
Not covered Not covered
Specialist Visit
Not covered Not covered
Hospital Admission
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
Urgent Care Facility
Not covered Not covered
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$25 copay
deductible waived
$25 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
Not covered Not covered
Skilled Nursing in lieu of hospital
30 days per calendar year*
20%
after deductible
20%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
Not covered Not covered
Home Health Care
in lieu of hospital
30 visits per calendar year*
20%
after deductible
20%
after deductible
Durable Medical Equipment
Not covered
++
Not covered
++
PHARMACY
Pharmacy Deductible
per individual
Not Applicable Not Applicable
Generic
Oral Contraceptives Included
$15 copay $15 copay
Preferred Brand
Oral Contraceptives Included
Not covered Not covered
Non-Preferred Brand
Oral Contraceptives Included
Not covered Not covered
Self Injectables
Not covered Not covered
Calendar Year Maximum
per individual*
Unlimited Unlimited
1514
Preventive and Hospital
Care 3000 (HSA Compatible)
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$3,000
$6,000
$6,000
$12,000
Coinsurance
(Members responsibility)
20%
after deductible
20%
after deductible
Non Facility
Services 50%
after deductible -
Facility Services
Coinsurance Maximum
Individual
Family
$2,000
$4,000
$4,000
$8,000
Out-of-Pocket Maximum
Individual
Family
$5,000
$10,000
$10,000
$20,000
Includes deductible
Lifetime Maximum* per insured
$5,000,000
Non-Specialist Office Visit
General Physician, Family Practitioner,
Pediatrician or Internist
Not covered Not covered
Specialist Visit
Not covered Not covered
Hospital Admission
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
Urgent Care Facility
Not covered Not covered
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$35 copay
deductible waived
$35 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
Not covered Not covered
Skilled Nursing in lieu of hospital
30 days per calendar year*
20%
after deductible
20%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
Not covered Not covered
Home Health Care
in lieu of hospital
30 visits per calendar year*
20%
after deductible
20%
after deductible
Durable Medical Equipment
Not covered
++
Not covered
++
PHARMACY
Pharmacy Deductible
per individual
Not Applicable Not Applicable
Generic
Oral Contraceptives Included
Not covered Not covered
Preferred Brand
Oral Contraceptives Included
Not covered Not covered
Non-Preferred Brand
Oral Contraceptives Included
Not covered Not covered
Self Injectables
Not covered Not covered
Calendar Year Maximum
per individual*
Not Applicable Not Applicable
Nonpreferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment,
which is based on the contracted maximum fee for participating providers in the particular
geographic area.
Above list of covered services is representative. A summary of exclusions is listed later in this
brochure. For a full list of benefit coverage and exclusions refer to the plan documents.
All products not available in all counties.
This material is for informational purposes only and is neither an offer of coverage nor dental
advice. It contains only a partial, general description of plan benefits or programs and does
not constitute a contract.
Aetna Advantage Plan options
Individual Dental PPO max plan
MEMBER BENEFITS Preferred NonPreferred
Annual Deductible per Member
(Does not apply to Diagnostic and
Preventive Services)
$25;
$75 family max.
$25;
$75 family max.
Annual Maximum Benefit Unlimited Unlimited
DIAGNOSTIC SERVICES
Oral exams
Periodic oral exam 100% ded. waived 100% ded. waived
Comprehensive oral exam 100% ded. waived 100% ded. waived
Problem-focused oral exam 100% ded. waived 100% ded. waived
X-rays
Bitewing — single film 100% ded. waived 100% ded. waived
Complete series 100% ded. waived 100% ded. waived
PREVENTIVE SERVICES
Adult cleaning 100% ded. waived 100% ded. waived
Child cleaning 100% ded. waived 100% ded. waived
Sealants — per tooth Discount Not covered
Fluoride application — with cleaning 100% ded. waived 100% ded. waived
Space maintainers Discount Not covered
BASIC SERVICES
Amalgam fillings — 2 surfaces 100% after ded. 100% after ded.
Resin fillings — 2 surfaces Discount Not covered
Oral Surgery
Extraction — exposed root or
erupted tooth
Discount Not covered
Extraction of impacted tooth
soft tissue
Discount Not covered
MAJOR SERVICES
Complete upper denture Discount Not covered
Partial upper denture (resin based) Discount Not covered
Crown — Porcelain with noble metal Discount Not covered
Pontic — Porcelain with noble metal Discount Not covered
Inlay — Metallic (3 or more surfaces) Discount Not covered
Oral Surgery
Removal of impacted tooth
partially bony
Discount Not covered
Endodontic Services
Bicuspid root canal therapy Discount Not covered
Molar root canal therapy Discount Not covered
Periodontic Services
Scaling & root planing —
per quadrant
Discount Not covered
Osseous surgery
per quadrant
Discount Not covered
ORTHODONTIC SERVICES
Discount Not covered
* Maximum applies to combined in and out-of-network benefits.
** Copay is billed separately and not due at time of service. Copay does not
count towards coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility care is the recognized charge for a service
or supply that is equal to or greater than the 80th percentile of the provider
charge data from the Ingenix Incorporated Prevailing HealthCare Charges
System (PHCS).
++ Coverage will be provided for care and treatment of diabetes; this includes
coverage for equipment and supplies used exclusively with diabetes
management and outpatient self-management training.
PPO 7500 with
Unlimited Primary Care
Visits plus Dental
MEMBER BENEFITS
In-Network Out-of-Network
+
Deductible
Individual
Family
$7,500
$15,000
$10,000
$20,000
Coinsurance
(Members responsibility)
20% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
$0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$2,500
$5,000
$2,500
$5,000
Out-of-Pocket Maximum
Individual
Family
$10,000
$20,000
$12,500
$25,000
Includes deductible
Lifetime Maximum* per insured
$5,000,000
Non-specialist Office Visit
Unlimited Visits
General Physician, Family Practitioner,
Pediatrican or Internist
$30 copay
deductible waived
$30 copay
deductible waived
Specialist Visit
Unlimited Visits
20%
after deductible
20%
after deductible
Hospital Admission
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
Emergency Room
$150 copay** (waived if admitted)
after deductible
Annual Routine Gyn Exam
No waiting period,
no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
$0 copay
deductible waived
Maternity
Not covered
(except for pregnancy complications)
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
$30 copay
deductible waived
$30 copay
deductible waived
Includes lab work and X-rays
Lab/X-Ray
20%
after deductible
20%
after deductible
Skilled Nursing In lieu of Hospital
30 days per calendar year*
20%
after deductible
20%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
20%
after deductible
20%
after deductible
Aetna will pay up to $25 per visit max.*
Home Health Care
In lieu of Hospital
30 visits per calendar year*
20%
after deductible
20%
after deductible
Durable Medical Equipment
Aetna will pay $2,000 per calendar year*
20%
after deductible
20%
after deductible
PHARMACY
Pharmacy Deductible
per Individual
Not Applicable Not Applicable
Generic
Oral Contraceptives Included
$15 copay $15 copay
Preferred Brand Name
Oral Contraceptives Included
Not covered Not covered
Non-Preferred Brand
Oral Contraceptives Included
Not covered Not covered
Self Injectables
Not covered Not covered
Calendar Year Maximum
per individual*
Unlimited Unlimited
16
5)
Aetna special
programs
Aetna Advantage plans include special
programs
1
to complement our standard health
insurance coverage. These programs include
health information programs and tools,
and offer you access to substantial savings
on products to help you stay healthy. These
programs are offered in addition to your Aetna
Advantage Plan and are NOT insurance.
Aetna Vision
SM
Discount Program
Aetna Vision
SM
discount program offers special savings
on eye exams, contact lenses, frames, lenses, LASIK eye
surgery, and eye care accessories.
Aetna Natural Products and Services
SM
Discount Program
Eligible Aetna members and their families can access
complementary health care products and services at
reduced rates through the Aetna Natural Products
and Services discount program. Members can save
on acupuncture, chiropractic care, massage therapy
and dietetic counseling as well as on over-the-counter
vitamins, herbal and nutritional supplements and other
health-related products.
Aetna Fitness
SM
Discount Program
Eligible Aetna members and their families can access
the GlobalFit™ national network of nearly 10,000
fitness clubs, in the United States and Canada, at
preferred rates*. In addition, members can access
other programs such as at-home weight loss programs,
home fitness options and even one-on-one health
coaching** services.
1 Availability varies by plan. Talk with your Aetna representative
for details.
* At some clubs, participation in this program may be restricted to
new club members.
** Provided by WellCall, Inc. through GlobalFit.
17
* Maximum applies to combined in and out-of-network benefits.
** Copay is billed separately and not due at time of service. Copay does not
count towards coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility care is the recognized charge for a
service or supply that is equal to or greater than the 80th percentile of the
provider charge data from the Ingenix Incorporated Prevailing HealthCare
Charges System (PHCS).
1918
Aetna Weight Management
SM
Discount Program
The Weight Management
SM
discount program can
help you achieve your weight loss goals by providing
you with a sensible weight loss plan and balanced
nutrition guide to fit your lifestyle. This program
provides Aetna members and their eligible family
members access to discounts on Jenny Craig
®
weight loss programs and products.
Aetna Hearing
SM
Discount Program
Aetna’s Hearing
SM
discount program helps Aetna
members and their families save on hearing exams,
hearing services and hearing aids.
Aetna Rx Home Delivery
®
With this mail order prescription drug program, order
prescription medications through our convenient and
easy-to-use mail order pharmacy. To learn more or obtain
order forms, visit www.AetnaRxHomeDelivery.com.
Informed Health
®
Line
Our 24-hour toll-free number that puts you in touch
with experienced registered nurses and an audio library
for information on thousands of health topics.
Aetna’s Secure Member Website
Register and log on to Aetna’s secure member website
to check claims status, contact Aetna Member Services,
estimate the costs of health care services, and more.
Aetna’s secure member website provides a starting point
to find answers about health care, types of treatment,
cost of services and more to help members make more
informed decisions. Plus, members have access to their
own Personal Health Record***, a single, secure place
where they can view their medical history and add other
health information.
*** The Aetna Personal Health
Record should not be
used as the sole source
of information about
your health conditions or
medical treatment.
WANT TO SAVE ON DENTAL
EXPENSES?
Vital Savings by Aetna
®
is a discount program
that provides you with dental savings. This is not
insurance. Enrolling in the program will give you
access to a network of providers who have
agreed to accept discounted rates for services.
To sign up today, visit www.vitalsavings.com
or call 1-877-698-4825.
For more information
on any of these programs,
please visit us online at
www.aetna.com.
The Vital Savings by Aetna
®
program (the
“Program”) is not insurance. The Program pro-
vides Members with access to discounted fees
pursuant to schedules negotiated by Aetna Life
Insurance Company for the Vital Savings by
Aetna
®
discount program. The Program does
not make payments directly to the providers
participating in the Program. Each Member is
obligated to pay for all services or products
but will receive a discount from the provid-
ers who have contracted with the Discount
Medical Plan Organization to participate in
the Program. Aetna Life Insurance Company,
151 Farmington Avenue, Hartford, CT 06156,
1-877-698-4825, is the Discount Medical
Plan Organization.
Discount programs provide access to discounted prices and are
NOT insured benefits.
2120
Things you
need to know
To qualify for an Aetna
Advantage Plan, you must be:
n
Under age 64 3/4 (If applying as a couple, both
you and your spouse must be under 64 3/4.)
n
Under age 24 for unmarried dependent children
n
Legal residents in a state with products offered by the
Aetna Advantage Plans
n
Legal U.S. residents for at least six continuous months
Your premium payments
Your rates are guaranteed not to increase for 12
months from your effective date once you’ve been
accepted for coverage. After that, your premiums may
change. Final rates are subject to underwriting review.
Your coverage
Your coverage remains in effect as long as you pay
the required premium charges on time, and as long as
you maintain eligibility in the plan. Coverage will be
terminated if you become ineligible due to any of the
following circumstances:
n
Non-payment of premiums
n
Becoming a resident of a state or location in which
Aetna Advantage Plans are not available
n
Obtaining duplicate coverage
n
For other reasons permissible by law
EASY-PAY
Simple Automatic Payments via Electronic
Funds Transfer (EFT)
Registration: Complete the payment section of the
Aetna Advantage Plans enrollment form. Select the EFT
option to approve the automatic withdrawal of your
initial premium and all subsequent premium payments.
Invoices: You will not receive a paper invoice when you
are enrolled in EFT. Payments will appear on your bank
statement as “Aetna Autodebit Coverage.”
Terminating: To terminate EFT, you will need to provide
Aetna with 10 days written notice prior to the date
your next EFT payment will be deducted. Without this
written notice, your bank account may be debited
for the next month’s premium. You will then need
to contact Aetna to have funds placed back in the
checking account.
Refunds: To process an EFT refund (placing money back
in member’s checking account), Aetna will require at
least five days after the withdrawal was made to ensure
valid payment.
Rejected transactions: If the EFT payment rejects for
any reason, Aetna will automatically terminate the EFT
and send you a letter saying you will receive paper
invoices. Processing time to reinstate EFT will be 30–60
days. If an EFT payment is rejected, you will need to pay
that payment by paper check or credit card.
Timing: Payments for Cycle 1 accounts (1st of the
month effective date) will be taken from your bank
account between the 3rd and the 10th of the month
the premium is due. Payments for Cycle 2 accounts
(15th of the month effective date) will be taken from
your bank account between the 18th and 23rd of the
month the premium is due.
2322
Levels of coverage & enrollment
n
You may be enrolled in your selected plan at the
premium charge.
n
You may be enrolled in your selected plan at a higher
premium, based on medical underwriting.
n
You may be declined coverage based on medical
underwriting.
Medical underwriting requirements
The Aetna Advantage Plans are not guaranteed
issue plans and require medical underwriting.
Some individuals may qualify as federally eligible
under the Health Insurance Portability Accountability
Act (HIPAA) or for Alaska’s Comprehensive Health
Association program under Alaska laws and regulations.
All applicants, enrolling spouses and dependents are
subject to medical underwriting to determine eligibility
and appropriate premium rate level.
We offer various premium rate levels based on the
medical underwriting of each applicant.
10-day right to review
Do not cancel your current insurance until you are
notified that you have been accepted for coverage. We’ll
review your enrollment form to determine if you meet
underwriting requirements. If you’re denied, you’ll be
notified by mail. If you’re approved, you’ll be sent an
Aetna Advantage Plan contract and ID card.
If, after reviewing the contract, you find that you’re not
satisfied for any reason, simply return the contract to
us within 10 days. We will refund any premium you’ve
paid (including any contract fees or other charges) less
the cost of any services paid on behalf of you or any
covered dependent.
Duplicate coverage
If you are currently covered by another carrier, you must
agree to discontinue the other coverage before or on the
effective date of the Aetna Advantage Plan. Do not cancel
your current insurance until you are notified that you have
been accepted for coverage and are certain that you are
keeping your Aetna Advantage Plan coverage.
Limitations & exclusions
Medical
These medical plans do not cover all health care expenses
and include exclusions and limitations. You should refer
to your plan documents to determine which health care
services are covered and to what extent.
The following is a partial 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). Services
and supplies that are generally not covered include, but
are not limited to:
n
All medical and hospital services not specifically
covered in, or which are limited or excluded by your
plan documents, including costs of services before
coverage begins and after coverage terminates
n
Ambulance coverage is limited to $5,000 per trip
n
Cosmetic surgery
n
Custodial care
n
Donor egg retrieval
n
Weight control services including surgical procedures
for the treatment of obesity, medical treatment, and
weight control/loss programs
n
Experimental and investigational procedures, (except
for coverage for medically necessary routine patient
care costs for Members participating in a cancer
clinical trial)
n
Charges in connection with pregnancy care other
than for pregnancy complications
n
Immunizations for travel or work
n
Implantable drugs and certain injectable drugs
including injectable infertility drugs
n
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
n
Non-medically necessary services or supplies
n
Orthotics
n
Over-the-counter medications and supplies
n
Radial keratotomy or related procedures
n
Reversal of sterilization
n
Services for the treatment of sexual dysfunction
or inadequacies including therapy, supplies or
counseling
n
Special or private duty nursing
2524
n
Therapy or rehabilitation other than those listed as
covered in the plan documents
n
Drug and alcohol dependency is not covered
n
Mental health is not covered
Dental
Listed below are some of the charges and services
for which these dental plans do not provide coverage.
For a complete list of exclusions and limitations, refer
to plan documents.
n
Dental Services or supplies that are primarily used to
alter, improve or enhance appearance. Negotiated rates
for cosmetic procedures available when a participating
dentist is accessed.
n
Experimental services, supplies or procedures
n
Treatment of any jaw joint disorder, such as
temporomandibular joint disorder
n
Replacement of lost or stolen appliances and certain
damaged appliances
n
Services that Aetna defines as not necessary for the
diagnosis, care or treatment of a condition involved
n
All other limitations and exclusions in your plan
documents
PRE-EXISTING CONDITIONS
During the first 12 months following your effective
date of coverage, no coverage will be provided for
the treatment of a pre-existing condition unless
you have prior creditable coverage.
A pre-existing condition is an illness, disease,
physical condition, or injury for which medical
advice, or treatment was recommended or received
and/or the use of prescription drugs of any kind
within six months preceding the effective date of
coverage. Services or supplies for the treatment
of a pre-existing condition are not covered for the
first 12 months after the member’s effective date.
If the member had continuous prior creditable
coverage within the 90 days immediately preceding
the signature on the application and meets certain
other requirements, then the pre-existing condition
exclusion of 12 months may not apply.
notes
If you need this material translated into another language,
please call Member Services at 1-866-565-1236.
Si usted necesita este material en otro lenguaje, por favor llame a
Servicios al Miembro al 1-866-565-1236.
This material is for information only and is not an offer or invitation
to contract. Plan features and availability may vary by location. Plans
may be subject to medical underwriting or other restrictions. Rates
and benefits may vary by location. Health/Dental insurance plans
contain exclusions and limitations. Investment services are indepen-
dently offered by the HSA Administrator. Providers are independent
contractors and are not agents of Aetna. Provider participation may
change without notice. Aetna does not provide care or guarantee
access to health services. Not all health services are covered. See
health insurance plan documents for a complete description of
benefits, exclusions, limitations and conditions of coverage. Plan fea-
tures are subject to change. Aetna receives rebates from drug mak-
ers 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. Home Delivery refers to Aetna
Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc.,
that operates through mail order. Health information programs pro-
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as of production date, however, it is subject to change.
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