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We want you to know? ?.? Mayfield Village Contact Information Account Executive: Telephone: e-mail: Charlie.Petretti@aetna.com Quote Highlights Product: Contract State: Policy Period: Quote ID: Chazles Petretti 330-659-8416 Aetna Choice@ POS Ohio 04/01/2010 - 03/31/2011 2900066 Funding: Prospective Location: Ohio - Northeast Dep. Age: -;p? 19, to age 25 1 FTS Option: Non Spec covere to the end of the month. Rate Summary Tier Lives Rate Monthl Cost Sin le 11 $494.20 $5,436.20 Cou le 16 $1,179.50 $18,872.00 EE + Child ren 11 $996.18 $10,957.98 Famil 21 $1,626.11 $34,148.31 Total 59 $69,414.49 Aema xvill rely on die information provided to determine whether a pcoposal will be issued. "l he responses aze assumed to be correct. it eirors or omissions aze suosequentiy found, Aetna reserves the right to revise rates or rescind the quote. Medicare lives have been excluded from this cate summacy. Benefit Highlights Plan Features In-Network Out-of-Network Plan Featuies In-Network Out-of-Network see individual see individual plan pays 80%; after Plan Coinsurance benefit benefit PCP Office Visit $10 copay deductible Individual/Family plan pays 80%; after Deductible none/none $300/$900 Specialist Office Visit $10 copay deductible Individual/Family plan pays 80%; after Coinsurance Limit $1,000/none $2,000/$4,000 Inpatient Hospital plan pays 100% deductible Outparient plan pays 80%; after Lifetime Maximum unlimited $5,000,000 Surgery/Hosp plan pays 100% deductible Retail Pharmacy $5/$10/$25 none Emergency Room $150 copay $150 copay Duiable Medical plan pays 80%; after Mail Order Pharmacv 2x none Equipment plan pays 100% deductible Age and frequency schedules apply to cectain benefits. Some benefits may have applicable state mandates and all plans will comply with state and fedexal legislations. The plan pays 100% after applicable copay(s). Federal Behavioral Health Pacity applies. Signature Date Tlus material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general descripaon of plan benefits or programs and does not consatute a contract. Consult the plan documents: Schedule of Benefits, CeLtificate of Coverage, Evidence of Covecage, Group Agxeement, and Group Insurance CectiFcate, to determine governing contractual provisions, including pcoceduces, exclusions and limitations ielaring [o Benefits described in this document are specific ro your plan and othectivise Aetna standazds will apply. While tlus matetial is believed to be accurate as of the print date, it is subject to change. 02-24-2010 ProposallD: 288701 page 1 EXHIBIT A