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2016 Aetna Health Savings Account (HSA) Plans Manage your health costs — Enjoy tax advantages — Make informed decisions — All in one health plan

1. The savings account: Aetna contributes and you can, too The Aetna HSA plan combines the protection of a health insurance plan with a tax-advantaged health savings account (HSA) that you can use to pay for qualified health expenses now, or save for future health costs.

The HSA Plan has three parts: 1. The savings account – Aetna puts money in this account and you can, too. You can use this money to pay for qualified out-of-pocket expenses, or you can save it for later. PayFlex® administers the Health Savings Accounts. Once enrolled, you’ll be able to access your account information by going to Aetna Navigator®. 2. The deductible – the amount you pay out of your own pocket for covered expenses before the medical plan starts to pay. The plan has a separate in-network deductible and an out-of-network deductible. In-network covered expenses will be applied to satisfy the in-network deductible and out-of-network covered expenses will be applied to satisfy the out-of-network deductible. Out-of-network expenses are not covered in the Aetna Open Access Select® plan or Aetna Whole HealthSM; therefore, they are not applied to the in-network deductible. 3. The medical plan – covers most of your expenses after the deductible has been met. Like a traditional bank savings account, an HSA earns interest and is protected by the Federal Deposit Insurance Corporation (FDIC), so your money can grow over time. And, because contributions to this account are free from federal and most state and local taxes, you’ll see some tax advantages. Also, any money left in the account at the end of the year rolls over to the next year and continues to earn interest. Best of all, since you own your HSA, you keep any accumulated balance in your account, even if you change health plans or leave Aetna.

In addition, once your account reaches $1,000, HSA investment funds are available to you. For additional information, call Aetna One Premier® at 1-800-558-0860 or visit the PayFlex portal via Aetna Navigator. If you choose to place funds in an investment account, your HSA becomes two linked accounts — a cash account and an investment account. A $2.00 service fee for maintenance of the investment account will be applied monthly and automatically deducted from your cash account. An investment in a mutual fund is not insured or guaranteed by the FDIC or any other government agency.

Establishing your HSA Please note that after you newly enroll in an HSA medical plan, it typically takes between 1 – 2 pay cycles from the date your medical coverage is effective for your account to be established at PayFlex. You will receive a letter in the mail from PayFlex notifying you when your HSA is established and ready for your use. Eligible expenses incurred on or after the date your HSA is established are eligible for tax-free distribution.

Aetna pays We will contribute $400 for individual coverage or $800 for family coverage in January for those enrolling during Annual Enrollment. If you are newly eligible, these amounts will be prorated based on your eligibility date. Contributions are deposited the payday after the HSA plan is established.

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Your optional contribution Once your account is established, you and your family members can also contribute. And you can change your contribution anytime during the year — even if you haven’t had a valid status change.

Who can contribute? According to IRS rules, you can contribute to your account as long as you are not covered under any other health plan that is not a high-deductible health plan (HDHP). For example, if you have coverage under an HDHP, and also are covered under the non-HDHP of your spouse’s employer, you will not be able to make contributions to an HSA. Likewise, if you are enrolled in a health care Flexible Spending Account (FSA), or if your medical expenses can be reimbursed by your spouse’s FSA, then you will not be able to contribute to an HSA. Also, if you cover your spouse through family coverage on an Aetna HSA medical plan, and your spouse is covered by a separate health plan that is not an HDHP, you may not contribute to an HSA. Also, if you are on Medicare, you won’t be able to contribute.

•  Earn Healthy Lifestyles Program incentives. If you elect an HSA plan, we’ll give you the choice of depositing your Healthy Lifestyles incentives into your HSA (pre-tax and able to earn interest) or receiving them directly in your paycheck (and subject to taxes). But you only have this choice when you are newly eligible or during Annual Enrollment. • Roll over an amount from an IRA to your HSA. This is a one-time rollover that you can complete at any time. You should contact your financial services agent and/or tax advisor to complete this type of rollover. Because the account is yours, Aetna is not involved in the process. The rollover amount will count toward your annual contribution limit. Trustee to trustee transfers from previous years’ employers will not count against the annual contribution limit. However, if you had an HSA, for example, January – June with one employer and then moved the plan over, you won’t be able to elect the full annual amount because you have already contributed to that tax year with another employer.

If you decide to contribute, you can do so in the following ways: • Have the amount deducted from your paycheck. The amount you select will automatically be deducted before eligible taxes are taken from your paycheck. Some states may tax this deduction. Talk to your tax advisor to learn more. Contribute a lump sum on an after-tax basis. You can do so in •  three ways: – M  ail your check with an HSA Deposit slip, which is available on the PayFlex portal accessed through your secure Aetna Navigator website or by calling PayFlex service center at 1-855-806-1070.

– E lectronic Funds Transfer (EFT) — Money can be transferred from a linked checking or savings account to an HSA on a one-time or recurring basis, subject to certain limitations. To sign up for an EFT, or for more information, visit the PayFlex portal accessed through Aetna Navigator. Note: You may be able to get a tax benefit for this deposit when you file your annual tax return — ask your tax advisor.



To obtain an HSA Transfer form, go to the PayFlex portal via Aetna Navigator or call PayFlex service center at 1-855-806-1070.

You can change your contribution on the YBR benefits enrollment site anytime during the year — even if you haven’t had a valid status change.

Your annual contribution cannot exceed a certain amount The total amount of contributions from all sources to your 2016 HSA cannot be higher than $3,350 per individual and $6,750 per family. Keep in mind that all contributions including Aetna’s contribution, your payroll deductions, lump-sum contributions, IRA rollover, and Healthy Lifestyles incentives can’t be higher than the IRS limits stated above. However, you’re allowed to contribute up to an additional $1,000 in catch-up contributions if you’re 55 or older.

–T  ransferring money from a Health Savings Account from a prior employer. You can obtain the Request to Rollover/ Transfer Funds form on the Payflex portal.

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John, a 45-year old computer programmer, enrolled in an HSA plan and wanted to contribute as much as he could for the year. And, since the contribution maximum for 2016 was $3,350 (for individual coverage), he wanted to avoid having his account exceed this amount. Here’s how he decided how much to contribute: • Aetna contributed $400 for the year.

Determining your contribution • Your eligibility to contribute to an HSA each month is generally determined by whether you have HDHP coverage on the first day of the month.

• John expects to receive a total of $500 in Healthy Lifestyles incentives during the year. • S o, he contributes $2,450 ($3,350 – $900) in payroll deductions during the year.

• Your maximum contribution for the year is the greater of: (1) the full annual contribution, or (2) the prorated amount. • Individuals who are eligible as of December 1 are allowed the full annual contribution. The full annual contribution is the maximum annual contribution for the type of coverage (Self-only or Family) you have on December 1 (plus catch-up contributions, if 55 or older by year end), regardless of the number of months you were an eligible individual in the year. If you are no longer an eligible individual on that date, both the HSA contribution and catch-up contribution apply pro rata based on the number of months of the year you were an eligible individual. The prorated amount is 1/12 of the maximum annual contribution for the type of HDHP coverage you have times the number of months you have that type of coverage. If your contribution is greater than the prorated amount, and you fail to remain covered by an HDHP for the entire following year, the extra contribution above the prorated amount is included in income and subject to tax penalties and/or IRS fees.

If you are 55 or older and not enrolled in Medicare in 2016, you may contribute an additional $1,000 as a “catch-up” contribution to your HSA. If you have a spouse who is 55 or older and not enrolled in Medicare, he or she will need to open a separate HSA account to qualify for his or her own catch-up contribution.

Keep in mind, if you’re hired in the fourth quarter and want to contribute the maximum contribution, your paycheck may not support the deductions. Please call the Aetna HR Contact Center if you have questions regarding how your goal may impact your paychecks.

Contribution examples If you first have family coverage on July 1, 2016, and keep coverage through December 31, 2016, you are allowed the full $6,750 family contribution to an HSA for 2016. If you fail to remain covered for all of 2016, $6,750 would be included in your income and subject to an additional tax. If you have family coverage from January 1, 2016, until June 30, 2016, and then cease having coverage, you’re allowed an HSA contribution of 6/12 of $6,750, or $3,375 for 2016. If you have family coverage from January 1, 2016, until June 30, 2016, and have self-only coverage from July 1, 2016, to December 31, 2016, you are allowed an HSA contribution of 6/12 x $6,750 plus 6/12 of $3,375, or $5,063 for 2016.

Remember to consider contributions from all sources when calculating your maximum contribution for the year, such as Aetna’s $400 contribution for individual coverage ($800 for family coverage) and other contributions — your payroll deductions, lump-sum contributions, IRA rollovers and Healthy Lifestyles incentives.

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Your account earns interest HSA contributions earn interest that is free from federal and most state and local taxes, with no minimum balance required. HSA participants are able to view interest earned on their HSAs (within a specified period) by going to the PayFlex portal on the Aetna Navigator site.

Ways to use your PayFlex HSA

1. Save the money for future qualified expenses (even in retirement) and pay current eligible expenses out of your pocket. Any balance you haven’t used by the end of the calendar year rolls over to the following year. Also, your account will continue to earn interest — free of federal taxes — as long as you have money in it. 2. Pay for certain qualified expenses from the account in a number of ways including: PayFlex MasterCard® Debit Card — You will automatically receive the debit card shortly after your enrollment. When you have an expense, simply write your debit card number on the provider’s bill and submit it for payment. When you use your debit card, there’s no need to provide documentation to substantiate the amount, but you should keep all receipts for expenses paid through your HSA for federal tax or audit purposes. Automatic Payment — You have the option to set up automatic payment for the amount due for your health care claims. You can set this up online by expense type (e.g., medical, dental and/or vision). If you have automatic payment turned on, the amount due for your claim will be automatically taken out of your HSA and sent to you. The amount due shown in your account is the amount reported to PayFlex by your Aetna health plan. Note: If you have automatic payment turned off, you can use the Connected Claims feature. It lets you choose how you want to handle your out-of-pocket expenses.

Online Bill Payment — Online bill payment gives you the ability to pay medical expenses directly from your HSA. Once enrolled, you can monitor, manage and schedule payments online, anytime. Payments can be on a one-time or recurring basis. Any of these options will help you pay your out-of-pocket costs quickly and easily — and you don’t have to complete any forms or wait for reimbursement. To sign up or for more information, go to the PayFlex portal on the Aetna Navigator site.

Important: • You cannot borrow against future contributions. You must have sufficient funds available in your HSA at the time you make a request for withdrawal. If you anticipate large expenses early in the plan year, you may need to pay for them out of your own pocket. • HSA contributions are usually available after 6 p.m. each payday; however, be sure to check the PayFlex portal via Aetna Navigator to confirm the deposit, as occasionally the contributions are not available until the next business day. • Y ou also can pay for non-qualified expenses from the account. If you are under the age of 65 and not disabled, any withdrawals that the Internal Revenue Service (IRS) considers as “non-qualified expenses” are considered taxable income.* They may be subject to income tax and an additional 20 percent penalty. • You can also set up goal limit reminders to confirm that you are not exceeding your IRS allowed limit by logging into your account from Aetna Navigator. When you use your account, some fees and penalties may apply. See page 14 for more details. *You can find more information on the Internal Revenue Service (IRS) website at www.irs.gov, but you should consult your tax advisor to learn about the rules in your state. Generally, a domestic partner does not qualify as a dependent. To see a full explanation of the “qualified expenses” that are allowed by the IRS, see Publication 502 at www.irs.gov.

Connected Claims — With connected claims, you can choose to have the money withdrawn directly from your HSA to pay for qualified Aetna medical, dental and/or vision out-of-pocket expenses. You have 3 options to take action: 1.  Pay your provider from your HSA 2. Reimburse yourself for what you have already paid out of pocket 3. Archive your transaction to take no action or to take action at a later date

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2. T  he deductible: You pay, then you can use your account First, Aetna wants you to take advantage of medical care that can aid in the early detection of disease and help you avoid more serious medical conditions. Accordingly, most preventive care is covered in full, and is not subject to your deductible. Age and frequency limits apply. Please check your plan for details. This care may include routine exams and shots, wellness exams for children and adults, certain screenings, routine mammograms, and vision and hearing exams. Your deductible is the amount you pay out of your own pocket for covered expenses before the medical plan starts to pay. The Aetna HealthFund HSA plans have a separate in-network deductible and an out-of-network deductible. In-network covered expenses will be applied to satisfy the in-network deductible and out-of-network covered expenses will be applied to satisfy the out-of-network deductible. Out-of-network expenses

are not covered in the Aetna Select plan or Aetna Whole Health; therefore, they are not applied to the in-network deductible. Once you’ve met your deductible — either by paying out of your own pocket or through your account — you move to the next stage, the medical plan.

HSA plan design changes The Affordable Care Act (ACA) impacts many of the benefits we offer to our employees. As new regulations emerge, we have to change our plans to make sure we comply with the law. This year you’ll see some changes to our HSA plans. We made the changes so that we could continue to offer you a wide range of plan options, but still comply with the ACA. These changes impact our plans in different ways, so it’s important to consider these as you look at your 2016 plan options.

2016 Plan

Here’s how it worked in the past

Here’s how it works now

HSA 1350 (replaces HSA 1300)

If you’ve enrolled with dependents, there’s no individual limit within the plan. Everyone’s costs go towards the family cost-sharing limits (deductible, coinsurance and out-of- pocket maximums).

These plans will continue to use this model.

If you’ve enrolled with dependents, there’s no individual limit within the plan. Everyone’s costs go towards the family cost-sharing limits (deductible, coinsurance and out-of- pocket maximums).

To make sure no individual’s costs within the plan are higher than the limit allowed by the ACA, these plans will have both individual and family cost-sharing limits.

HSA 1700 Aetna Whole Health Plans (will use HSA 1350 in 2016) HSA 2600 (replaces HSA 2500) HSA 5000

Once someone hits the individual deductible and out-of-pocket limit, his/her health care costs are then covered at 100 percent for the rest of the plan year. This allows you to save money and start having your plan pay sooner.

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3. T  he medical plan: The majority of your costs are covered Once you meet your deductible, your medical plan picks up most of the eligible medical and prescription drug costs. You pay a percentage of the costs (called “coinsurance”), and your share is less when you use health care professionals in the Aetna network. •T  here is a limit to the amount you have to pay for covered services (called an “out-of-pocket limit”) with HSA plans. If you reach that amount, the HSA medical plan pays 100 percent of your covered medical and pharmacy expenses for the rest of the year. • If you use doctors who are out of network, Aetna pays a percentage of the amount for that service. That amount is based on what we consider to be a “reasonable” rate. That could be a percentage of what Medicare pays or, if no Medicare rate is available, what we determine the market rate to be. If the doctor’s fee is more than that amount, you may have to pay the difference. Please see Key features of the Aetna HSA plans on page 12 to learn more about which plans don’t have out-of-network coverage.

Your network In 2016, our HSA plans will be supported by the new Aetna Premier Care network (APCN). It’s replacing the Aexcel and Aetna Performance networks. This new network makes it easier to find the care you need. There are just two tiers — providers are either in or out of network. It’s that simple. In most cases, over 90 percent of providers who were in network in our old networks will be in network for APCN as well. Check DocFind® to confirm your providers are in the APCN.

How you access care and pay your doctors • Y ou can use in-network or out-of-network doctors. But, your out-of-pocket costs typically will be lower if you use an in-network doctor. • In general, if you use in-network doctors, you don’t need to make a payment at the time you receive services. Your in-network doctor will submit the claim to Aetna and send you a bill for any amount you owe.

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How you access care and pay your doctors For the most part, the way you access care — and pay your doctors — is the same for all HSA plans: • In the HSA plan, you can use in-network or out-of-network doctors. But, your out-of-pocket costs are lower when you visit an in-network doctor. Except for emergencies, out-of-network services are not covered in the Aetna Open Access Select plan or Aetna Whole Health plans. • In general, if you use in-network doctors, you don’t need to make a payment at the time you receive services. Your innetwork doctor will typically submit the claim to Aetna and send you a bill for the amount you owe. You can set up automatic payments, which automatically sends you the amount due for your claim if dollars are available in your HSA. Or, you can withdraw money from your HSA to pay for part or all of your qualified expenses using your PayFlex MasterCard Debit Card or online bill payment. You also can choose to pay for your covered health care expenses out of pocket and save your HSA balance to help pay future health-related expenses.

  How John’s Aetna HealthFund HSA 1350 plan (with individual coverage)

covered his knee surgery In December, John had to have knee surgery. Because he went to an in-network doctor, the surgery cost about $4,500. Here’s how John’s Aetna HealthFund HSA 1350 (individual coverage) plan covered his expenses: John needed to pay his deductible of $1,350. He withdrew money from his HSA (which had a balance of $5,000).



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Eligible expenses (cost of surgery): Deductible – John pays from his HSA Remaining expenses after the deductible has been met

$4,500 –$1,350 $3,150

Remaining HSA balance: $3,650 ($5,000 – $1,350) Since John has met his deductible, he moves to the next stage — the medical plan, which picks up most of the costs. Because he went to an in-network surgeon and surgical facility, his plan paid 80% of the remaining expenses.



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Remaining expenses: John’s HSA 1700 medical plan paid 80% John paid the remaining 20% from his HSA

$3,150 –$2,520 $ 630

John’s HSA now has a remaining HSA balance of: $3,020 ($3,650 – $630)

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Your Aetna HSA plan options A choice of HSA plans are available to you based on your zip code. Each offers different deductibles and out-of-pocket maximums. • Aetna Whole Health HSA 1350 (offered in select locations) Arizona: Phoenix – Aetna Whole Health – Banner Health Network Phoenix – Aetna Whole Health – Arizona Care Network

Texas Austin – Aetna Whole Health – Seton Health Alliance (NEW) Dallas-Fort Worth – Aetna Whole Health – Baylor Scott & White Quality Alliance Houston – Aetna Whole Health – Memorial Hermann Accountable Care Network San Antonio – Aetna Whole Health – Baptist Health System & Health Texas Medical Group

California: Orange County & South Los Angeles County – Aetna Whole Health – Memorial Care (NEW)

Washington: Aetna Whole Health in Puget Sound:

Sacramento, San Joaquin and Yolo counties – Aetna Whole Health – Hill Physicians & Mercy Medical Group (NEW)

Seattle – The Polyclinic (NEW)

San Diego – Aetna Whole Health – Sharp Colorado: N. CO, Denver Metro & Colorado Springs – Aetna Whole Health – Colorado Front Range (NEW) Connecticut: Statewide – Aetna Whole Health – Hartford HealthCare & Value Care Alliance (NEW) Maine: Portland – Aetna Whole Health – Maine

Seattle – Pacific Medical Centers (NEW) Seattle – Providence-Swedish (NEW) Seattle – Rainier Health Network (NEW)

• Aetna Open Access Select HSA 1350 • Aetna HealthFund HSA 1700 • Aetna HealthFund HSA 2600 • Aetna HealthFund HSA 5000

Nebraska: Omaha – Aetna Whole Health – CHI Health Accountable Care Network (NEW) Ohio: Cincinnati – Aetna Whole Health – Mercy Health Cincinnati (NEW) Oklahoma: Oklahoma City – Aetna Whole Health – INTEGRIS Health Partners Network (NEW) Pennsylvania: Harrisburg – Aetna Whole Health – PinnacleHealth

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Your prescription drug plan At Aetna, we are focused on helping you achieve your level of optimal health. One of the ways we do that is by helping you get the most from your prescription drug plan. That’s why we want you to know how the prescription drug plan works, which benefits are offered through the plan and what tools are available to you. If you are enrolled in an Aetna medical plan as a regular employee, you and your eligible dependents are automatically covered by a comprehensive prescription drug plan.

How Aetna HSA medical plans cover your prescriptions Prescription benefits are tied to your medical plan. This means you pay 100 percent of the negotiated, discounted costs of medical and prescriptions until you meet your deductible. Certain preventive prescriptions are not subject to deductible. For a complete list, see the Health tab on AccessHR or visit your Aetna Navigator account after you have enrolled. Once your deductible is met, your covered prescription drug expenses are paid under the plan. You will then pay a copayment for generic drugs or a percentage, called coinsurance, for brandname drugs. You can choose to pay your prescription drug expenses through your Health Savings Account (HSA) by using your PayFlex MasterCard debit card at the point of service. Or, you can choose not to use your HSA funds for out-of-pocket prescription drug expenses in order to save your HSA for other qualified expenses. An out-of-pocket limit applies to prescription drug expenses under the Aetna HSA plans. After the deductible is met and you reach the out-of-pocket limit, the plan pays 100 percent of the negotiated cost of your eligible medical and prescription drug expenses for the remainder of the year. With the HSA plan, you must use either a participating pharmacy, Aetna Rx Home Delivery® or Aetna Specialty Pharmacy® to receive coverage. Since Aetna’s systems are integrated with the participating pharmacy systems, the pharmacist will know whether you need to pay an amount to satisfy the deductible or if the prescription drug plan benefits apply and you need to pay a copayment or a percentage of the cost.

About prescription drugs Three general classes of prescription drugs are available to you: •G  eneric drugs: prescription drugs that are therapeutically equivalent to brand-name drugs because they contain the same active ingredients in the same doses. The same rigorous United States Food and Drug Administration (FDA) quality and safety reviews that apply to brand-name drugs also apply to generic drugs. Substituting generic drugs for brand-name drugs may help lower your health care expenses, allowing you to maximize the value of your benefits. • Brand-name drugs: prescription drugs that the innovator or marketer prohibits other drug companies from manufacturing at this time. Generally, you will see a cost savings if you use a preferred brand-name drug rather than a nonpreferred brandname drug. • Specialty drugs: prescription drugs that may be injected, infused or taken by mouth. Usually, you can’t get these drugs at a local retail pharmacy. Examples of covered medications include Enbrel®, used to treat rheumatoid arthritis; and Avonex®, used to treat multiple sclerosis. You will generally see a cost savings if you use a preferred specialty drug rather than a nonpreferred specialty drug.

Rx changes to promote generics Choosing generic drugs helps keep your prescription costs lower. They’re also just as effective. The FDA requires generic drugs to have the same strength, quality, purity and stability as brand-name drugs. So, we’re adding a Choose Generics program that supports the use of generics. In 2016, you or your doctor can still request brand-name drugs even when a generic is available. However, you’ll pay the brand name cost share plus the difference in cost between the brand and generic drug.

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Amount you pay after you meet the annual deductible Any pharmacy in our network (up to a 30-day supply) Type of drug

Maintenance Choice: Aetna Rx Home Delivery (up to a 90-day supply)

Coinsurance/ copay

Maximum coinsurance/ copay

Coinsurance/ copay

Maximum coinsurance/ copay

Non-specialty medicines: • Generic •  Preferred brand name •  Nonpreferred brand name

$10 35% 50%

$10 $75 $125

$25 35% 50%

$25 $150 $250

Specialty medications (self-injectables): •  Preferred brand name •  Nonpreferred brand name

10% 30%

$125 $250

N/A N/A

N/A N/A

Note: The Aetna HealthFund HSA 5000 doesn’t require a prescription coinsurance/copay amount after the individual deductible has been met.

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Key features of the Aetna HSA plans: Aetna Health Savings Accounts (HSAs) Can I contribute money?

Yes

Does Aetna contribute money?

Yes $400 for individual coverage $800 for family coverage Employer contributions are prorated for mid-year entry

When I receive covered services, is the amount automatically taken out of my account?

No. The amount is not automatically taken out of your account, unless you set up automatic payments on the PayFlex portal. This automatically takes the amount due for your medical, dental and/or vision claim and sends it to you. Important: Any money that is contributed by either you or Aetna is available only as it is deposited into your account. You cannot borrow against future contributions.

Is there a deductible?

Yes. You can pay the deductible out of your own pocket or from your account, using your PayFlex debit card, online bill payment or online withdrawal. Once you meet your deductible, the medical plan begins to pay. In-network covered expenses will apply toward the in-network deductible. Out-ofnetwork covered expenses will apply toward the out-of-network deductible. Out-of-network expenses are not covered in the Aetna Open Access Select plan or Aetna Whole Health; therefore, they will not apply to the in-network deductible.

Are there tax advantages?

Yes. The amount Aetna contributes and any contributions deducted from your paycheck are exempt from federal and most state and local taxes. Any earned interest — and any amount you use to pay for qualified expenses for yourself or for a qualified dependent* — are exempt from these taxes, as well. *If the dependent does not qualify as an IRS tax dependent (generally, a child under age 19 or age 24 if a full-time student, dependent on you for support and living with you at least 50 percent of the time; or an individual that lives with you for the full year and receives more than 50 percent of their support from you), and the account is used to pay for their medical expenses, this use will be considered a non-qualified withdrawal and treated as a taxable distribution. The tax penalty for a non-qualified withdrawal from an HSA account is 20 percent. For more information, call PayFlex service center at 1-855-806-1070.

Can I roll over any remaining balance to the next year?

Yes. Your HSA account balance automatically rolls over from one year to the next.

Can I take the money with me if I switch medical plans or leave Aetna?

Yes. You own the account, so you keep it, even if you change medical plans or stop working at Aetna. See the HSA Fee Schedule on page 14.

What happens to the money if Aetna discontinues the plan?

You own the account, so you keep it, even if Aetna discontinues the plan. See the HSA Fee Schedule on page 14.

Do prescription drug expenses apply toward the deductible or coinsurance limit, or to the out-of-pocket deductible?

The deductible is waived for certain preventive drugs only. Eligible prescription drug expenses do apply toward the deductible or coinsurance and out-of-pocket limits.

Is there an out-of-pocket limit,** which caps the total amount that I will pay annually for covered health care expenses (deductible and coinsurance limit)?

Yes. Once you reach your out-of-pocket limit,** your plan will cover 100 percent of your eligible medical and pharmacy drug costs for the rest of the year.

**This limit does not apply to non-covered expenses, such as amounts for out-of-network care or for non-emergency use of emergency room. Refer to your plan’s Summary of Benefits and Coverage for more information.

Out-of-network covered expenses, if covered, will apply toward the out-of-network deductible. These expenses will count toward the out-of-network out-of-pocket maximum.

In-network covered expenses will apply toward the in-network deductible. These expenses also will count toward the in-network out-of-pocket maximum.

The descriptions of Aetna’s benefits in this brochure summarize only the highlights of the plans. You can find more details about your plan in the Summary of Benefits and Coverage and the Summary Plan Description. If any statement in these descriptions conflicts with applicable plan documents, the plan documents will govern. The company retains the right to amend or terminate its benefits at any time. Also, participation in the plans described in this brochure does not guarantee your continued employment or the right to any benefits, except as specifically provided in the plans. The people featured in the examples in this brochure are not real. They are for illustrative purposes only to help you understand your benefits.

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When you need help or information Aetna One Premier For plan-specific information, call Aetna One Premier at 1-800-558-0860. Aetna Navigator Go to the PayFlex site where you can manage your HSA, get information about medical and prescription benefits, print order forms for Aetna Rx Home Delivery, and review your pharmacy claims and other Aetna claims history. Available on AetNet, Working At Aetna and www.aetna.com. Aetna Rx Home Delivery Online access to order forms and patient registration forms at www.aetna.com/aetnarxhomedelivery. Call customer service with your questions and to fill a prescription at 1-888-792-3862. Have your doctor fax your prescription(s) and completed order forms to 1-877-270-3317.

Aetna Specialty Pharmacy Get information about Aetna Specialty Pharmacy and ask questions about specialty drugs. Call customer service with your questions at 1-866-782-ASRX (1-866-782-2779) or visit www.aetnaspecialtyrx.com.

AccessHR For general information about medical and prescription drug benefits, visit AccessHR on Working at Aetna. Aetna HR Contact Center For general information about medical and prescription drug benefits or payroll deductions, call 1-800-AETNA-HR (1-800-238-6247). PayFlex service center For assistance with your Aetna HSA, call 1-855-806-1070, 24 hours a day, 7 days a week.

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Health Savings Account (HSA) Fee Schedule for A The fees listed below are for your HSA administered by PayFlex. You’ll find additional information on these fees in your Health Savings Custodial Account Participant Agreement (“Agreement”). You’ll be responsible for these fees unless noted as optional or paid by Aetna. You can view this fee schedule online at any time. You can also view the Agreement from your online account. If you have any questions, you can call PayFlex Member Services at 1-855-806-1070, 24 hours a day, 7 days a week

Description

Fee

Tips to Help Avoid Fees

Monthly Account Maintenance Fee

$4.00

This is the monthly fee to administer your account. Aetna currently pays this fee while you’re actively at work and have an HSA as part of your primary medical plan. If you change plans and no longer have an HSA or terminate employment with Aetna, you’ll be moved into a retail account and you’ll need to pay this fee.

Monthly Investment Account Fee

$2.00

You would incur this fee only if you open an investment account. Once you open an investment account, you would be charged this fee every month that the account stays open.

Monthly Account Statement via Paper (includes postage)

$1.50

This is a monthly fee. To help avoid this fee, sign up to receive your statements online at no charge instead of by mail.

Stop Payment (per check)

$25.00

You would incur this fee if you have the bank stop a check or electronic payment.

Non-Sufficient Funds (NSF) Fee (overdraft) (per occurance)

$25.00

You would incur this fee if you overdraw your account. To help avoid this fee, make sure that you have enough funds in your HSA before you make a payment. You can check your balance online at any time.

Deposit Item Returned (per occurance)

$25.00

You would incur this fee if you make a deposit that’s rejected. You can help avoid this fee by making sure you have enough funds in your personal bank account to cover a transfer to your HSA.

In accordance with the terms and conditions of your Agreement, we reserve the right to change any of the above fees. If we do change a fee, we’l send you written notice. We also reserve the right to charge additional fees. We’ll notify you before we start charging for any new fee. If your High Deductible Health Plan (HDHP) coverage status or employment status changes, your monthly account maintenance fee and other transaction fees may also change. This material is for informational purposes only and is not an offer of coverage. It doesn’t contain legal or tax advice. You should contact your legal counsel or your tax adviser if you have any questions or if you need additional information. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about PayFlex, go to payflex.com. Investment services are independently offered through a third-party financial institution. By transferring funds into an HSA investment account, you can potentially benefit from capital appreciation in the value of mutual fund holdings. However, you will also be exposed to a number of risks, including the loss of principal, and you should always read the prospectuses for the mutual funds you intend on purchasing to familiarize yourself with these risks.The HSA investment account is an optional, self-directed service. We do not provide investment advice for HSA investment account participants.You are solely responsible for any investment account decisions you make. Mutual funds and brokerage investments are not FDIC-insured and are subject to investment risk, including fluctuations in value and the possible loss of the principal amount invested. The prospectus describes the funds’ investment objectives and strategies, their fees and expenses, and the risks inherent to investing in each fund. Investors should always read the prospectus carefully before making any investment decision. System response and account access times may vary due to a variety of factors, including trading volumes, market conditions, system performance and other factors. Financial Sanctions Exclusions. If benefits or reimbursement provided by this Agreement violate or will violate any economic or trade sanctions, the benefits are immediately considered invalid. PayFlex Systems USA, Inc. cannot make payments for claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or a country under sanction by the United States, unless permitted under a written Office of Foreign Asset Control (OFAC) license. © 2015 PayFlex Systems USA, Inc. 69.03.901.1A (9/15) (Aetna Inc.)

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Important Disclosure Information Health Savings Account Custodial Agreement (Under section 223(a) of the Internal Revenue Code) Please keep this agreement with your HSA records. Thank you for choosing PayFlex Systems USA, Inc. (“PayFlex,” “Custodian,” “us” or “we”) as the custodian of your Health Savings Account (“HSA”). You and we agree to be bound by the terms of this agreement in connection with administration of your HSA. By applying for and funding your HSA (other than as a rollover from another HSA), you represent that you: (1) are covered under a qualified high deductible health plan (HDHP); (2) are not also covered by any other health plan that is not an HDHP (with certain exceptions for plans providing preventive care and limited types of permitted insurance and permitted coverage); (3) are not enrolled in Medicare; and (4) cannot be claimed as a dependent on another person’s tax return.

month in which you enrolled in the HDHP) are included in your gross income for the year in which you ceased to be eligible and those amounts are subject to an additional 10% excise tax. Please consult with your tax advisor for further information. If you are age 55 or older and not enrolled in Medicare you may be eligible to contribute an additional “catch-up” amount to your HSA. See materials included with your enrollment or consult your tax advisor for information about these contribution limits. Contributions in excess of the maximum annual contribution limit are subject to an excise tax. However, the catch-up contributions are not subject to an excise tax.

Article III You are permitted to rollover funds on a tax-free basis from a Medical Savings Account (MSA) or another HSA. MSA and HSA rollovers do not decrease the amount that may be contributed to the HSA during the year.

Article IV It is your responsibility to determine whether contributions to this HSA have exceeded your maximum annual contribution limit. If contributions to this HSA exceed the maximum annual contribution limit, you must notify us of the excess amount. It is also your responsibility to request the withdrawal of the excess contribution and any net income attributable to it.

Article I

Article V

We will accept cash contributions in U.S. Dollars to your HSA from you or on your behalf (by your employer, a family member or other person). However, we will not accept contributions that exceed the maximum annual amount for family coverage plus any allowable catch-up contribution. Catch-up contributions are allowable for you if you are 55 or older.

Your interest in the balance of your HSA account is non-forfeitable.

You may make contributions for any tax year at any time before the deadline for filing your federal income tax return for that year (without extensions).

Article II You can make contributions to an HSA up to certain limits as established by the Internal Revenue Service (IRS). If you enroll in the high deductible plan after the plan year has begun, you may still contribute up to the maximum contribution amount, provided that you maintain HDHP coverage for a 12-month testing period. (The testing period begins with the last month of the taxable year in which you enrolled and ends on the last day of the 12 month period following such month) If you do not maintain continuous HDHP coverage for the testing period (other than for reason of death or disability), any HSA contributions which could not have been made otherwise (i.e., contributions attributable to any month(s) preceding the

Article VI Funds in your HSA cash account will be credited interest by us as described in Article VII below. We may also make available other investment options available to you. You will have exclusive control over any decision to allocate HSA funds to these options. No funds in your HSA may be invested in life insurance contracts or in collectibles. The assets of your HSA may not be commingled with other property except in a common trust fund or common investment fund. Neither you nor we will engage in any prohibited transaction with respect to this account (such as borrowing or pledging the account) as defined by the Internal Revenue Code (“Code”).

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Article VII Your HSA account will include a cash account, and, if available in your HSA program, may also include an investment account. Cash account: Funds in your cash account are maintained in an aggregate account established for the benefit of all of our HSA holders at an insured financial institution of our choosing. You will not be exposed to any investment risk on balances in your cash account. We will credit interest on the balance in your HSA cash account above the required minimum balance for interest, if any, that applies to your account. We will calculate this interest on a nightly basis (reflecting the available cash balance in your HSA cash account and using the interest rate in effect that night), track this interest during the course of a month and credit interest earned to your HSA cash account no later than the second banking day of the next month. The interest rate for the month will be disclosed to you in your on-line account transaction history and (where applicable) in periodic account statements. Interest is compounded monthly and computed on a 365-day year basis (366 in leap year if your HSA is open on February 29). Interest will be calculated only on available funds as described in Article XVI below. If you close your HSA in midmonth you will not receive interest for that month. Your HSA cash balance is eligible for FDIC insurance up to applicable FDIC deposit limits. We may receive compensation in connection with aggregate cash account balances we deposit. You are entitled to interest on your cash account as specified herein, but otherwise not to any portion of the compensation we may receive in connection with the accounts in excess of calculated interest amounts we pay you. We reserve the right in our sole discretion to change the rate of interest you receive on HSA cash account balances and to establish and apply different rates of interest depending on the amount of your cash account balance. Investment account: If available under your HSA program you may elect to transfer a portion of your HSA to an investment account. Through this investment account you will be able to invest in one or more mutual funds from a designated slate of mutual fund investment choices allowed under applicable law that will be made available to you. You must be a U.S. person (a U.S. citizen or a U.S. resident alien) to enroll in an HSA investment account. Participation in the investment account will be subject to whatever additional terms and conditions (“Investment Account Terms and Conditions”) made applicable to the arrangement. Any amounts you allocate to an investment account will not be FDIC insured and will not be included in your cash balance for purposes of crediting interest as described in this section. To open an investment account you must have a minimum of $1,000 in your HSA cash account. We may charge an annual

or monthly maintenance fee for participation in the HSA investment account service. For a statement of these fees see the materials provided with your enrollment or contact us. To the extent otherwise unpaid, we may deduct these fees from your HSA. In addition, there may be service fees associated with the mutual fund options. Such fees are disclosed in the prospectus for each applicable fund option. Service fees, eligibility criteria, minimum investment requirements and initial funds transfer amounts are subject to change. Investments in mutual fund options can be made only by transferring funds from your HSA cash account to an investment account. Proceeds from mutual fund redemptions can be reinvested in other mutual funds from the designated mutual fund slate or transferred back into your HSA cash account. Funds held in the HSA investment account cannot be accessed via an HSA debit card. You must redeem mutual fund shares and transfer the proceeds back to the cash account in order to make purchases, including the payment of any medical-related expenditure, with these funds. The fund slate available to you may change (e.g. modify or replace) from time to time. If a fund ceases to be available we may liquidate your investment in that fund and deposit the proceeds in your cash account. We may also liquidate your investments and transfer the proceeds to your cash account in the event your cash account becomes overdrawn. By transferring funds into an HSA investment account you can potentially benefit from capital appreciation in the value of mutual fund holdings. However, you will also be exposed to a number of risks, including the loss of principal, and you should always read the prospectuses for the mutual funds you intend on purchasing to familiarize yourself with these risks. The HSA investment account is an optional, self-directed service. We do not provide investment advice for HSA investment account participants. You are solely responsible for any investment account decisions you make.

Article VIII Distributions of funds from your HSA may be made at your direction. If you elect to receive and use a debit card in conjunction with your HSA, you agree to review and accept the debit card terms and conditions contained in the cardholder agreement that will be supplied to you with the debit card. Distributions from your HSA that are used exclusively to pay or reimburse qualified medical expenses for you, your spouse or your dependents (who qualify as dependents for health coverage purposes) are tax-free from federal income tax. However, distributions that are not used for qualified medical expenses are included in your gross income and are subject to an additional 20% tax on that amount. The additional 20%

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tax does not apply if the distribution is made after your death, disability, or reaching age 65. We are not required to determine whether the distribution is for the payment or reimbursement of qualified medical expenses. You alone are responsible for substantiating that the distribution is for qualified medical expenses and you must report any such distributions on your annual tax return (Form 8889) and maintain records sufficient to show, if required, that the distribution is tax-free.

Article IX You have the right to designate one or more beneficiaries to whom your HSA funds will be distributed upon your death. To be valid, any such beneficiary designation must be delivered to us prior to your death on a form provided by us, or a form that is otherwise acceptable to us. Any such beneficiary designation may be revoked by you at any time by delivering written notice of the revocation to us, and shall be automatically revoked upon receipt by us of a subsequent beneficiary designation in valid form bearing a later execution date. You understand that the consent of your spouse may be necessary if you wish to name a person other than or in addition to your spouse as beneficiary or to change an existing beneficiary designation. If there is no valid beneficiary designation on file with us at the time of your death, your legal spouse will be deemed to be your beneficiary. If you are not married at the time of your death, the funds will be paid to your estate. You represent and warrant that any beneficiary designation submitted to us is complete, accurate and satisfies all legal requirements under applicable law. We may presume that a beneficiary is legally competent until we receive written notice to the contrary. If you die before the entire interest in your HSA is distributed, the remaining HSA balance will be disposed of as follows: (1) If the beneficiary is your spouse, the HSA will become your spouse’s HSA as of the date of your death (unless otherwise specified by applicable laws), and (2) If your beneficiary(ies) is not your spouse, the HSA will cease to be an HSA as of the date of your death and the fair market value of the account will be taxable to that person (or your estate) in the tax year that includes the date of death, reduced by any payments made for your qualified medical expenses if paid within one year of your death and any applicable fees.

Article X You will provide us with information necessary for us to prepare any report or return required by the IRS. We will prepare and submit any report or return as prescribed by the IRS.

Article XI Notwithstanding the remaining articles of this agreement, the provisions of Articles I through X and this sentence are controlling. Any provision that is inconsistent with section 223 of the Code or IRS published guidance will be void.

Article XII We may amend this agreement from time to time without advance notice to you to comply with the provisions of the Code or IRS published guidance. We may also make other amendments from time to time by sending a notice of the amendment to you. You will be deemed to accept the amendment unless you terminate this agreement within 30 days of receiving the notice.

Article XIII We may charge an annual or monthly maintenance fee for your HSA as well as other service and administrative fees. For a statement of these fees see the materials provided with your enrollment or contact us. We may deduct these fees from your HSA. Certain fees may be paid in whole or in part by your employer or other third party. If you leave the employer or these payments are terminated for other reasons you will be responsible for paying all fees in order to maintain your HSA. You may also be responsible for additional fees if you elect additional features or investment options made available to you in connection with your HSA. We may change our fees from time to time with notice to you. New fees will be effective 30 days after the notice is given. In addition to fees we charge, we may receive compensation in connection with the aggregate HSA cash account balances we deposit. Such compensation will not exceed the U.S. Prime Rate (as published in the Wall Street Journal).

If a request for a transfer is made pursuant to the terms of a divorce or separation agreement, we must receive the request within 90 days of the effective date of the divorce or separation instrument. Transferring your interest to someone other than your spouse may subject you to income tax and penalties on the transferred amount.

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Article XIV We may engage sub-custodians, financial institutions, fund managers, clearing brokers or other contractors (collectively our “contractors”) to provide services for your HSA. We may change these contractors at any time without notice to you. Some contractors may be our affiliates and we or the affiliate may receive compensation from such arrangements. In particular, we may on your behalf: (1) open an account at a depository institution of our choice and deposit all or a portion of your HSA funds into that account, (2) close any account we have opened on your behalf and transfer the funds to another account, (3) execute on your behalf any documents related to the opening, maintenance and closing of any depository account, and (4) withdraw from these accounts fees and expenses of your HSA. Some services (such as a debit card, or investment fund) may require that you enter into an additional agreement or abide by additional terms and conditions that we or our contractors provide to you. If you accept the service you will be deemed to accept the agreement or terms and conditions that apply to it. We may share fees and/or fee revenue with our contractors, including contractors that are our affiliates. Any fees paid by you or your HSA will be disclosed to you and your continued use of our services or the services of our contractors will be considered approval of such fees. In addition, our contractors may receive interchange fees from parties other than us for use of HSA debit cards. The interchange fees may vary, but in all cases will be equal to or less than the highest possible fee allowed for all card transactions. Neither you nor we are responsible for the payment of any interchange fee and such fees may not be deducted from your HSA.

Article XV We and our contractors will be entitled to rely on all information and instructions you provide. If we or our contractors fail to receive instructions with respect to any transaction, receive instructions that are ambiguous, or believe in good faith that a requested transaction is in dispute, we or our contractor may take no action until further clarification acceptable to us is received. Neither we nor our contractors will be responsible for losses that may result from your instructions, actions or failure to act, nor will we or they be responsible for any taxes, fines, penalties, judgments or expenses you incur in connection with your HSA. If you appoint an authorized agent to act on your behalf with respect to your HSA or this agreement we and our contractors may rely on all information and instructions provided by your agent. Neither we nor our contractors will be required to verify the validity of the agent’s appointment or be responsible for

losses that may result from your agent’s instructions, actions or failure to act. You will reimburse us or our contractors for any additional costs or liabilities we or they may incur as a result of actions or inactions of your agent.

Article XVI Unless we otherwise agree, all funds deposited in your HSA will be in cash and in U.S. Dollars, accompanied by a completed deposit form. Funds deposited into your HSA cash account will be available for withdrawal after the day of deposit depending upon the type of deposit and in accordance with Federal Reserve Regulation CC. The day of deposit is the banking day on which the deposit is received before the cut-off time specified for the place where the deposit is received. Deposits received after the applicable cut-off time will be deemed received the next banking day. Deposits by electronic funds transfer will be available on the day we determine the deposit is made. Automated clearing house (ACH) credits to the cash account will be available on the day of receipt. ACH withdrawals from other accounts to your HSA cash account generally will be available two banking days after the drawdown request is submitted by us to the ACH system. Deposits by check generally will be available no earlier than three banking days after the day of deposit. In certain circumstances, longer delays in availability may apply such as for large dollar items, checks requiring special handling, checks drawn on out of state banks, emergency situations such as failure of communications or computer equipment and for any other reason as permitted by applicable law or regulation. If funds are being credited to your HSA account through payroll deduction, please check with your employer regarding the timing and application of the payroll deposits. We reserve the right to make adjustments to your HSA balances to correct funding errors on deposits made to your account. Interest will be credited only on available funds.

Article XVII You may also elect to have claims submitted automatically to your HSA from health plans we designate. We may rely on evidence of this election from your health plan to execute these withdrawals automatically on your behalf until we receive written notice from you that you have terminated this election. We may put a hold on funds in your HSA for amounts authorized but not yet paid in connection with a debit, credit or automatic submission transaction. Held amounts will not be available to pay other expenses. We may refuse any request for withdrawal, whether automatic or not, if the available funds in your HSA account are less than the amount of the requested withdrawal. If your HSA cash account balance falls to or below $0.00 we will not process

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any further withdrawals until additional funds are deposited or transferred from the investment account. We have the right to liquidate assets in your HSA investment account if necessary to make distributions or to pay fees, expenses, taxes, penalties or surrender charges properly chargeable against your HSA. If you fail to direct us as to which assets to liquidate, we will decide, in our complete and sole discretion, and you agree not to hold us liable for any adverse consequences that result from our decision.

Article XVIII You may terminate this Agreement at any time by giving us prior written notice. If you provide a completed HSA transfer form to us at the time of termination we will transfer the balance of your HSA to a qualified replacement account administrator you designate. We may liquidate any investments in your HSA investment account in order to execute this transfer. If you do not provide a completed HSA transfer form at time of termination we will pay the balance of your HSA account to you. We may report this payment as a non-qualified withdrawal from your HSA. We may terminate this Agreement at any time by giving written notice to you. We may resign as custodian, without your consent, upon written notice to you. Upon our resignation, we will either appoint a successor custodian (see next paragraph), ask you to appoint a successor custodian, or we will distribute the remaining assets in the HSA to you. If the Agreement is terminated, we will cancel any outstanding debit card associated with your account at the time of termination. If we distribute the assets, you are responsible for the tax consequences of the distribution. We shall not be liable for any actions or failures to act on the part of any successor custodian or trustee, nor for any tax consequences you may incur that result from the transfer or distribution of your assets pursuant to this section. If this Agreement is terminated, we may charge to your HSA a reasonable amount of money that we believe is necessary to cover any associated costs, including but not limited to, one or more of the following; •  Any fees, expenses or taxes chargeable against your HSA; • Any penalties or surrender charges associated with the early withdrawal of any savings instrument or other investment in your HSA. Appointment of Successor Custodian: Pursuant to this Article XVIII, we may resign as custodian and appoint a successor custodian that we choose. The successor custodian (or trustee) must be a bank (as defined in Code Section 408(n)), an insurance company (as defined in section 816), or another person who satisfies the IRS requirements for HSA custodial duties. The appointment of a successor custodian will become

effective immediately; provided, however, that you will retain your right to terminate this Agreement pursuant to this Article XVIII. If you do not exercise your right to terminate this agreement and request a complete distribution or designate a new custodian or trustee, you will be deemed to have automatically accepted the successor custodian. In the event that a successor custodian is appointed, the successor custodian’s HSA Custodial Agreement and all related account documentation will automatically become applicable. In such case, you will receive a copy of the new custodial agreement and related documentation.

Article XIX Any notice we provide to you under this agreement will be considered effective when we send it to you at your last address we have in our records. Any notice you provide to us will be considered effective when we receive it. No one other than we and you (or in the event of your death your duly designated beneficiary) will have any rights under this agreement. This agreement will be governed by the laws of the United States and the State of Nebraska.

Article XX You will indemnify and hold us harmless from and against any claim, loss, liability, damage, cost, or expense (including reasonable attorney’s fees) that arises or may arise in connection with this agreement or your HSA (including, without limitation, any action we take or do not take in honoring your instructions including, but not limited to, all verbal, electronic or facsimile instructions received with respect to your HSA, or in connection with our honoring of any subpoena or court order relating to your HSA), except liabilities, damages, costs, or expenses that arise from our breach of any of our duties under this agreement. In connection with this agreement and your HSA, we are not responsible for any act or failure to act that is reasonable under the circumstances or that is consistent with any applicable laws, rules or regulations of the applicable state law, or with general commercial practices of banks. WE ARE NOT LIABLE FOR ANY INDIRECT, CONSEQUENTIAL, EXEMPLARY, PUNITIVE OR SPECIAL DAMAGE, LOSS, COST OR EXPENSE OF ANY TYPE OR NATURE, REGARDLESS OF THE FORM OF THE ACTION OR THEORY OF RECOVERY, AND EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF ANY OF THE FOREGOING. EXCEPT AS SET FORTH IN THIS AGREEMENT, WE DO NOT MAKE ANY REPRESENTATIONS AND WARRANTIES WHETHER EXPRESS, STATUTORY OR IMPLIED.

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Acceptance of Agreement Your application for an HSA forms part of this agreement and constitutes your acceptance of its terms. You will provide us any information we reasonably request in order to verify your identity. We may refuse to accept any application for an HSA at our discretion; however our acceptance of your application constitutes our agreement to the terms above. Please keep this agreement with your HSA records. You do not need to return it to us or file it with the IRS.

© PayFlex Systems USA, Inc. 41.03.430.1

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CCG AETNAHR-0229_HSA (9/15) ©2015 Aetna Inc.