By Dana Mattioli And Liz Hoffman 

As Aetna Inc. and Humana Inc. sealed their $34.1 billion merger this week, there were a few other elephants in the room.

Namely, the three other major health insurers lurking around the deal talks, while having some of their own-- UnitedHealth Group Inc., Anthem Inc. and Cigna Corp.

Humana, for example, was being pursued by both Aetna and Cigna, say people familiar with the talks. Meanwhile, Cigna was rebuffing advances from Anthem, which made public its $47.5 billion bid for Cigna last month after private approaches failed to yield a deal.

The dynamic raised questions on the Humana side about Cigna's commitment to a purchase: Did it really want Humana, or did it want negotiating capital with Anthem? Humana worried Cigna was using it in an effort to play hard-to-get with Anthem, said one person familiar with the Louisville, Ky., insurer's thinking.

Cigna, which has been engaged in rekindled talks with Anthem, also expressed interest in Humana as late as Thursday evening, said one person. The deal with Hartford, Conn.-based Aetna was announced shortly after 2 a.m. EDT Friday.

Humana urged Cigna to make a cash-heavy offer, which Cigna resisted, people familiar with the matter said. Humana worried that Cigna shareholders--whose approval would be needed for any takeover bid funded heavily by new stock--might not approve a Humana buyout knowing the Anthem offer was there for the taking.

A cash bid wouldn't require Cigna shareholders' approval, so its board could move ahead despite the Anthem offer on the table.

Shareholders often prefer to be sellers, getting a bird in hand, rather than buyers, bearing the risks of an acquisition.

Aetna's offer for Humana involves a big issuance of new stock, meaning Aetna's own shareholders must approve it. But that structure was more acceptable to Humana, one person said, because even though The Wall Street Journal has reported that UnitedHealth has approached Aetna about a takeover, no public offer is on the table for shareholders to consider.

Not that it was all smooth sailing between Aetna and Humana.

The two companies had been near an agreement on Tuesday, according to people familiar with their talks, but negotiations around the breakup fee, payable in case the announced deal fell apart, raised tensions, some of the people said.

The two sides eventually agreed on a breakup fee of 3.75% of the deal's value, currently about $1.4 billion, payable to either company if the agreement is scuttled by a topping bid for the other, people familiar with the matter said.

Such breakup fees are commonly promised to companies in Aetna's shoes, the buyers, to compensate for the sting of seeing a rival bidder steal their prize. But it is unusual to see it go both ways, and suggests Humana was protecting itself against the possibility UnitedHealth makes a play for Aetna.

The structure of the Aetna-Humana deal leaves time for UnitedHealth to interlope, because the deal involves Securities and Exchange Commission review and shareholder approval. Those efforts can take months.

Write to Dana Mattioli at dana.mattioli@wsj.com and Liz Hoffman at liz.hoffman@wsj.com

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