Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, disability leave, pensions, etc. you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee.  Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members.  Family members include your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. 

The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member in another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below.  A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below. 

Natural children,  adopted children, and stepchildren

Coverage: Natural children, adopted children and stepchildren are covered until their 26th birthday.

Foster children

Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements.  Contact your human resources office or retirement system for additional information.

Children incapable of self-support

Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage.  Contact your human resources office or retirement system for additional information.

Married children

Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance

Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother’s maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM. 
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM. 

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be paid according to the 2024 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment if final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices.  You can also visit OPM's website at:
https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends;
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage. 

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-537-9384 or visit our website at
www.aetnafeds.com.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

Precertification is the process of collecting information prior to inpatient admissions and performance of selected ambulatory procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or you. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments.

This Plan is available to our members in those FEHBP service areas identified in Section 1. You can go directly to any network specialist for covered services without a referral from your primary care provider. Whether your covered services are provided by your selected primary care provider (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-537-9384 or write to us at Aetna, P.O. Box 14079, Lexington, KY 40512-4079. You may also request replacement cards through our Aetna Member website at www.aetnafeds.com.

You get covered care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance and you will not have to file claims. If you use our Open Access program you can receive covered services from a participating network specialist without a required referral from your primary care provider or by another participating provider in the network.

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members.  Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards. 

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

We list Plan providers in the provider directory, which we update periodically.  The list is also on our website.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached at
www.aetnafeds.com for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.  We list these in the provider directory, which we update periodically.  The list is also on our website at www.aetnafeds.com.

FEHB Carriers must have clauses in their in-network (participating) providers agreements.  These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount.  If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

It depends on the type of care you need.  First, you and each family member must choose a primary care provider.  This decision is important since your primary care provider provides or arranges for most of your health care. 

Your primary care provider can be a general practitioner, family practitioner, internist or pediatrician. Your primary care provider will provide or coordinate most of your health care.

If you want to change primary care providers or if your primary care provider leaves the Plan, call us or visit our website. We will help you select a new one.

Your primary care provider may refer you to a specialist for needed care or you may go directly to a specialist without a referral. However, if you need laboratory, radiological and physical therapy services, your primary care provider must refer you to certain plan providers.

Here are some other things you should know about specialty care:

• If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Program plan; or
  • reduce our Service Area and you enroll in another FEHB plan;

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care.  This includes admission to a skilled nursing or other type of facility.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services department immediately at 800-537-9384. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

Since your primary care provider arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

You must get prior approval for certain services. Failure to do so will result in services not being covered.

Precertification is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

Your primary care provider has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. You must obtain prior authorization for:

• Inpatient confinements (except hospice) - For example, surgical and nonsurgical stays; stays in a skilled nursing facility or rehabilitation facility; and maternity and newborn stays that exceed the standard length of stay (LOS)
• Ambulance - Precertification required for transportation by fixed-wing aircraft (plane)
• Autologous chondrocyte implantation
• Cataract surgery
• Certain mental health services, inpatient admissions, Residential treatment center (RTC) admissions, Partial hospitalization programs (PHPs), Transcranial magnetic stimulation (TMS) and Applied Behavior Analysis (ABA);
• Chiari malformation decompression surgery
• Cochlear device and/or implantation
• Coverage at an in-network benefit level for out-of-network provider or facility unless services are emergent. Some plans have limited or no out-of-network benefits
• Covered transplant surgery
• Dialysis visits -When request is initiated by a participating provider, and dialysis to be performed at a nonparticipating facility
• Dorsal column (lumbar) neurostimulators: trial or implantation
• Endoscopic nasal balloon dilation procedures
• Electric or motorized wheelchairs and scooters
• Functional endoscopic sinus surgery
• Gender affirming surgery
• Hip surgery to repair impingement syndrome
• Hyperbaric oxygen therapy
• In-network infertility services and pre-implantation genetic testing
• Lower limb prosthetics, such as: Microprocessor controlled lower limb prosthetics
• Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider
• Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
• Osseointegrated implant
• Osteochondral allograft/knee
• Private Duty Nursing (see Home Health services)
• Proton beam radiotherapy
• Reconstructive or other procedures that maybe considered cosmetic, such as:
  • Blepharoplasty/canthoplasty
  • Breast reconstruction/breast enlargement
  • Breast reduction/mammoplasty
  • Excision of excessive skin due to weight loss
  • Gastroplasty/gastric bypass
  • Lipectomy or excess fat removal
  • Surgery for varicose veins, except stab phlebectomy
• Shoulder arthroplasty
• Site of Service-when requested at an Outpatient hospital setting and when is one of the following:
  • Anal fistula surgery
  • Angle ligament repair
  • Arthrocentesis
  • Breast tissue excision
  • Carpal tunnel surgery
  • Circumcision - older than 28 days of age
  • Colonoscopy
  • Colposcopy
  • Complex wound repair
  • Conization of cervix
  • Cystourethroscopy
  • Dilation and curettage (D&C)
  • Esophagogastroduodenoscopy (EGD)
  • Excision of lesion of tendon sheath or joint capsule
  • Ganglion excision
  • Hemorrhoidectomy
  • Hernia repair
  • Hysteroscopy
  • Implant removal (i.e., screw)
  • Intranasal dermatoplasty
  • Intravitreal injection
  • Iridotomy/iridectomy, laser surgery
  • Knee joint manipulation under general anesthesia
  • Laparoscopic cholecystectomy
  • Laparoscopy, diagnostic
  • Laryngoscopy
  • Lithotripsy
  • Mohs surgery
  • Nasal bone fracture, closed treatment
  • Neuroplasty, ulnar
  • Orchiopexy
  • Penile angulation correction
  • Prostate biopsy
  • Septoplasty
  • Skin tissue transfer or rearrangement
  • Subcutaneous soft tissue excision
  • Tendon sheath incision
  • Tenodesis of long tendon of biceps
  • Tonsillectomy (age 12 or older)
  • Transurethral electrosurgical resection of prostate (TURP)
  • Trigger point injections
  • Turbinate resection
  • Tympanostomy
• Spinal procedures, such as:
  • Artificial intervertebral disc surgery (cervical spine)
  • Arthrodesis for spine deformity
  • Cervical laminoplasty
  • Cervical, lumbar and thoracic laminectomy/laminotomy procedures
  • Kyphectomy
  • Laminectomy with rhizotomy
  • Sacroiliac joint fusions
  • Spinal fusion surgery
  • Vertebral corpectomy
  • Vertebroplasty/Kyphoplasty
• Uvulopalatopharyngoplasty, including laser-assisted procedures
• Ventricular assist devices
• Whole exome sequencing
• Drugs and medical injectables (including but not limited to blood clotting factors, botulinum toxin, alpha-1-proteinase inhibitor, palivizumab (Synagis), erythropoietin therapy, intravenous immunoglobulin, growth hormone and interferons when used for hepatitis C)*
• Special Programs (including but not limited to BRCA genetic testing, Chiropractic precertification, Diagnostic Cardiology (cardiac rhythm implantable devices, cardiac catheterization), Hip and knee arthroplasties, National Medical Excellence Program®, Pain management, Polysomnography (attended sleep studies), Radiation oncology, Radiology imaging (such as CT scans, MRIs, MRAs, nuclear stress tests), Sleep Studies, Transthoracic Echocardiogram*

*For complete list refer to:
www.aetna.com/health-care-professionals/precertification/precertification-lists.html or the Behavioral Health Precertification list. The specialty medication precertification list can be found at: www.aetnafeds.com/pharmacy.php.

Members must call 800-537-9384 for authorization.

First, your physician, your hospital, you, or your representative, must call us at 800-537-9384 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee's name and Plan identification number;
• patient's name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 45 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you verbally within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours (1) of the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-537-9384. You may also call OPM's FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-537-9384. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision.  This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within one (1) business day following the day of the emergency admission, even if you have been discharged from the hospital. 

You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than a total of three (3) days or less for vaginal delivery or a total of five (5) days or less for cesarean section, then your physician or the hospital must contact us for additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.

        You or your provider must send the information so that we receive it within 60 days
        of our request.  We will then decide within 30 more days.

        If we do not receive the information within 60 days, we will decide within 30 days of
        the date the information was due.  We will base our decision on the information we
        already have.  We will write to you with our decision.

  3.  Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care provider, you pay a copayment of $15 per office visit, or you pay a copayment of $30 per office visit when you see a participating specialist under High Option and a copayment of $25 per office visit to your primary care provider, or you pay a copayment of $55 per office visit when you see a participating specialist under Basic Option.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

Example: Under the Aetna Saver Option you will need to meet the deductible of $1,000 for Self Only enrollment or $2,000 for Self Plus One or Self and Family enrollment.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your prior option to the deductible of your new option.

Coinsurance is the percentage of our allowance that you must pay for your care. 

Example: In our Plan, you pay 30% of our allowance for durable medical equipment.

• Network Providers agree to accept our Plan allowance so if you use a network provider, you never have to worry about paying the difference between our Plan allowance and the billed amount for covered services.
• Non-Network Providers (for Dental PPO Option only): If you use a non-network provider for preventive dental care, you will have to pay 50% of our negotiated rate and the difference between our Plan allowance and the billed amount.
• You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

After your (copayments and coinsurance) total $5,000 for Self Only enrollment or $10,000 for Self Plus One enrollment or Self and Family enrollment for the High Option, $6,000 for Self Only enrollment or $12,000 for Self Plus One enrollment or Self and Family enrollment for the Basic Option and $6,500 for Self Only enrollment or $13,000 for Self Plus One enrollment or Self and Family enrollment for the Aetna Saver Option in any calendar year, you do not have to pay any more for covered services.  Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical expenses at 100%. The remaining balance of the Self Plus One and Self and Family out-of-pocket maximum can be satisfied by one or more family members. If you are enrolled in our Aetna Medicare Rx – offered by SilverScript. You will have a separate $2,000 out of pocket maximum for your prescription costs. Once you reach this maximum you will no longer pay a cost share for covered drugs. This $2,000 will also apply to the Plan’s out-of-pocket maximum, see above for additional details.
However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Dental services (Please Note for High and Basic Options: $5 copayments for DMO preventive care and $20 deductible for PPO preventive care count towards your out-of-pocket maximum.  All other dental service expenses do not count toward your out-of-pocket maximum).  
• Infertility services covered under the medical benefit.

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the Plan's calculation of your out-of-pocket maximum is reflected accurately.

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.
A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by certain nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills. Any claims subject to the No Surprises Act will be paid in accordance with the requirements of such law.  Aetna will determine the rate payable to the out-of-network provider based on the median in-network rate or such other data resources or factors as determined by Aetna. Your cost share paid with respect to the items and services will be based on the qualifying payment amount, as defined under the No Surprises Act, and applied toward your in-network deductible (if you have one) and out-of-pocket maximum.

Please note: there are certain circumstances under the law where a provider can give you notice that they are out of network and you can consent to receiving a balance bill. For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.aetnafeds.com or contact the health plan at 800-537-9384.

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians

• In physician’s office
  • Office medical evaluations, examinations, and consultations
  • Second surgical or medical opinion

$15 per primary care provider (PCP) visit

$30 per specialist visit

$25 per primary care provider (PCP) visit

$55 per specialist visit

• During a hospital stay
• In a skilled nursing facility

•  In an urgent care center

• At home

$20 per PCP visit

$30 per specialist visit

$25 per PCP visit

$55 per specialist visit

• Teladoc Health® consult

$40 per consult

• CVS Health Virtual Care™ consult

$0 per consult

$0 per consult

Please see www.aetnafeds.com/tools.php for information on medical and behavioral telehealth services.

Members will receive a welcome kit explaining the telehealth benefits.

Refer to Section 5(e) for behavioral health telehealth consults.

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and electroencephalogram (EEG)
• Sleep Studies

Nothing if you receive these services during your office visit; otherwise if service performed by another provider,

$15 per PCP visit

$30 per specialist

Nothing if you receive these services during your office visit; otherwise if service performed by another provider,

$25 per PCP visit

$55 per specialist

Diagnostic tests limited to:

• Bone density tests - diagnostic
• CT scans/MRIs/PET scans
• Diagnostic angiography
• Genetic testing - diagnostic*
• Nuclear medicine

Note: The services need precertification. See Section 3 "Services requiring our prior approval". 

*Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient's medical condition.

$100 copay

• Genetic Counseling and Evaluation for BRCA Testing
• Genetic Testing for BRCA-Related Cancer*

*Note: Requires precertification. See Section 3 "Services requiring our prior approval".

• Routine physicals - one (1) exam every calendar year

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
  https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at
  https://shorturl.at/hovHM.
  
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at
  https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder
• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

Note: Some tests provided during a routine physical may not be considered preventive. Contact member services at 800-537-9384 for information on whether a specific test is considered routine.

Routine mammogram - covered

• One (1) every calendar year; or when medically necessary

Nothing

Nothing

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Not covered:

• Physical exams, immunizations, and boosters required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

• Well-child visits, examinations, and immunizations other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to 
  https://brightfutures.aap.org
• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at 
  https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at 
  https://shorturl.at/hovHM
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Note: Some tests provided during a routine physical may not be considered preventive. Contact member services at 800-537-9384 for information on whether a specific test is considered routine.

• Well-child care charges for routine examinations, immunizations and care (up to age 22)
  • Seven (7) routine exams to from birth age 12 months
  • Three (3) routine exams from age 12 months to 24 months
  • Three (3) routine exams from age 24 months to 36 months
  • One (1) routine exam per year thereafter to age 22
     
• Examinations such as:
  • Vision screenings through age 17 to determine the need for vision correction*
  • Hearing exams through age 17 to determine the need for hearing correction
  • Routine examinations done on the day of immunizations  (up to age 22)

*For routine eye refraction, see Vision Services

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Refer to Note

Refer to Note

Not covered:

• Physical exams, immunizations and boosters required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

Complete maternity (obstetrical) care, such as:

• Routine Prenatal care - includes the initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. 
• Screening and counseling for prenatal and postpartum depression

Note: Items not considered routine include: (but not limited to)

• Amniocentesis
• Certain Pregnancy diagnostic lab tests
• Delivery including Anesthesia
• Fetal Stress Tests
• High Risk Specialist Visits
• Inpatient admissions
• Ultrasounds

• Screening for gestational diabetes
• Delivery
• Postnatal care

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will extend your inpatient stay if medically necessary, but you, your representative, your participating doctor, or your hospital must precertify the extended stay.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay including the initial examination of a newborn child covered under a Self Only, Self Plus One or Self and Family enrollment. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for maternity care (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

Note: Also see our Enhanced Maternity Program in Section 5 (h).

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

No copay for routine prenatal care or the first postpartum care visit

$15 for PCP visit or $30 for specialist visit for postpartum care visits thereafter

Note: If your PCP or specialist refers you to another specialist or facility for additional services, you pay the applicable copay for the service rendered.

No copay for routine prenatal care or the first postpartum care visit

$25 for PCP visit or $55 for specialist visit for postpartum care visits thereafter

Note: If your PCP or specialist refers you to another specialist or facility for additional services, you pay the applicable copay for the service rendered.

A range of voluntary family planning services limited to:

• Contraceptive counseling on an annual basis
• Surgically implanted contraceptives
• Generic injectable contraceptive drugs, such as Depo-Provera
• Intrauterine devices (IUDs)
• Diaphragms
• Tubal ligation

Note:  We cover injectable contraceptives under the medical benefit when supplied by and administered at the provider's office.  Injectable contraceptives are covered at the prescription drug benefit when they are dispensed at the Pharmacy.  If a member must obtain the drug at the pharmacy and bring it to the provider's office to be administered, the member would be responsible for both the Rx and office visit copayments.  We cover oral contraceptives under the prescription drug benefit.

Nothing

Nothing

Voluntary sterilization (See Surgical Procedures Section 5(b))

Nothing for women

For men:

$15 per PCP visit

$30 for Specialist visit

Nothing for women

For men:

$25 per PCP visit

$55 for Specialist visit

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Infertility is a disease defined as when a person is unable to conceive or produce conception after one year of egg-sperm contact when the individual attempting conception is under 35 years of age, or after six months of egg-sperm contact when the individual attempting conception is 35 years of age or older.  Egg-sperm contact can be achieved by regular sexual intercourse or artificial insemination (intrauterine, intracervical, or intravaginal) as stated in our medical clinical policy bulletin (see Section 10. for definition of Medical Necessity for additional details on Aetna’s Clinical Policy).  This definition applies to all individuals regardless of sexual orientation or the presence/availability of a reproductive partner.  Infertility may also be established by the demonstration of a disease or condition of the reproductive tract such that egg-sperm contact would be ineffective.

Diagnosis and treatment of infertility, such as:

• Testing for diagnosis and surgical treatment of the underlying medical cause of infertility.
• Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease.* **

Comprehensive Infertility Services

• Artificial insemination (AI)* ** and monitoring of ovulation:
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
  • Intravaginal insemination (IVI)

Note: We limit Artificial Insemination to 3 cycles per calendar year. The Plan defines a “cycle” as:

• An attempt at ovulation induction while on injectable medication to stimulate the ovaries with or without artificial insemination
• An artificial insemination cycle with or without injectable medication to stimulate the ovaries
• Ovulation induction cycle(s) while on injectable medication to stimulate the ovaries. *
• Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician *
• Injectable fertility drugs including but not limited to menotropins, hCG, GnRH agonists, and intravenous immunoglobulins (IVIG). (See Section 5f for coverage)*

You are eligible for these covered services if:

• You or your partner have been diagnosed with infertility.
• You have met the requirement for the number of months trying to conceive through egg and sperm contact.
• Your unmedicated day 3 Follicle Stimulating Hormone (FSH) level and testing of ovarian responsiveness meet the criteria outlined in Aetna’s infertility clinical policy.

Note: The Plan does not cover infertility drugs under the medical benefit. See Section 5(f) for coverage.

Aetna’s National Infertility Unit

Our NIU is here to help you and is staffed by a dedicated team of registered nurses and infertility coordinators. They can help you with understanding your benefits and the medical precertification process. You can learn more at www.aetnainfertilitycare.com or call the NIU at 1-800-575-5999  (TTY: 711).

* Subject to medical necessity

** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384. Your network provider will request approval from us in advance for your infertility services. If your provider is not a network provider, you are responsible to request approval from us in advance.

50% of all charges

Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See Section 4 for details)

50% of all charges

Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See Section 4 for details)

Not covered:

• All infertility services associated with or in support of an Advanced Reproductive Technology (ART) cycle. These include, but are not limited to:
  • Imaging, laboratory services, and professional services
  • In vitro fertilization (IVF)
  • Zygote intrafallopian transfer (ZIFT)
  • Gamete intrafallopian transfer (GIFT)
  • Cryopreserved embryo transfers
  • Gestational carrier cycles
  • Any related services, products or procedures (such as intracytoplasmic sperm injection (ICSI) or ovum microsurgery).
• Cryopreservation (freezing), storage or thawing of eggs, embryos, sperm or reproductive tissue (unless noted as covered)
• All charges associated with or in support of surrogacy arrangements for you or the surrogate. A surrogate is a female carrying her own genetically related child with the intention of the child being raised by someone else, including the biological father
• Any charges associated with care required to obtain ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for ART procedures except as stated above
• The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers (or surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational carrier
• Reversal of sterilization surgery.
• Treatment for infertility when the cause of the infertility was a previous sterilization with or without surgical reversal. This includes tubal ligation, hysterectomy and vasectomy only if obtained as a form of voluntary sterilization.
• Services and supplies related to the above mentioned services, including sperm processing
• Cost of home ovulation predictor kits or home pregnancy kits
• Drugs related to the treatment of non-covered benefits
• Infertility services that are not reasonably likely to result in success
• Elective fertility preservation, such as egg freezing sought due to natural aging;
• Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention
• Storage costs
• Obtaining sperm from a person not covered under this plan
• Infertility treatment when a successful pregnancy could have been obtained through less costly treatment
• Infertility treatment when infertility is due to a natural physiologic process such as age related ovarian insufficiency (e.g. perimenopause, menopause)as measured by an unmedicated FSH level at or above 19 on cycle day two or three of your menstrual period or other abnormal testing results as outlined in Aetna’s infertility clinical policy
• Oral and Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH agonists. (except where otherwise noted in Section 5f)
• Any infertility service rendered that requires precertification without a prior authorization
• Coverage for services received by a spouse or partner who is not a covered member under the plan

• Testing and treatment
• Allergy injections

Note: You pay the applicable copay for each visit to a doctor’s office including each visit to a nurse for an injection.

$15 per PCP visit

$30 per specialist visit

$25 per PCP visit

$55 per specialist visit

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants in Section 5(b).

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis

Note: Copayment does not apply for peritoneal dialysis when self-administered. Copayment will apply if services are rendered in home by a plan provider.

• Intravenous (IV) Infusion Therapy in a doctor’s office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services.)
• Growth hormone therapy (GHT)

Note: Growth hormone therapy is covered under Medical Benefits; office copay applies. We cover growth hormone injectables under the prescription drug benefit.

Note: We will only cover GHT when we preauthorize the treatment. Call 800-245-1206 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information and it is authorized by Aetna. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

• Applied Behavior Analysis - (see Section 5(e) for benefits)

$30 per visit

Note: If you receive these services during an inpatient admission, then facility charges will apply. See section 5(c) for applicable facility charges.

$55 per visit

Note: If you receive these services during an inpatient admission, then facility charges will apply. See section 5(c) for applicable facility charges.

60 visits per person, per calendar year for physical or occupational therapy or a combination of both for the services of each of the following:

• Qualified Physical therapists
• Occupational therapists

Note:  We only cover therapy when a physician:

• Orders the care;
• Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• Indicates the length of time the services are needed.

Note: Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living. Inpatient therapy is covered under Hospital/Extended Care Benefits.

• Physical therapy to treat temporomandibular joint (TMJ) pain dysfunction syndrome

Note: Physical therapy treatment of lymphedemas following breast reconstruction surgery is covered under the Reconstructive surgery benefit - see section 5(b). 

$30 per visit, nothing during a covered inpatient admission

Note: If you receive these services during an inpatient admission or outpatient visit, then facility charges will apply. See section 5(c) for applicable facility charges.

$55 per visit, nothing during a covered inpatient admission

Note: If you receive these services during an inpatient admission or outpatient visit, then facility charges will apply. See section 5(c) for applicable facility charges.

Not covered:

• Long-term rehabilitative therapy

• Twenty visits per condition per member per calendar year of pulmonary rehabilitation to treat functional pulmonary disability
• Cardiac rehabilitation following a qualifying event/condition is provided for up to 3 visits a week for a total of 18 visits.

$55 per visit, nothing during a covered inpatient admission

• Habilitative services for children under age 19 with congenital or genetic birth defects including, but not limited to, autism or an autism spectrum disorder and developmental delays. Treatment is provided to enhance the child's ability to function. Services include occupational therapy, physical therapy and speech therapy.

Note: No day or visit limit applies.

$55 per visit, nothing during a covered inpatient admission

60 visits per person, per calendar year

Note:  For children up to age 19, no day or visit limit applies for habilitative therapy, see section 5(a) Habilitative therapy

$55 per visit, nothing during a covered inpatient admission

• Audiological testing and medically necessary treatment for hearing problems
• Hearing testing for children through age 17 (See Preventive care, children)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants (See Orthopedic and prosthetic devices section and the note referring to Section 5(b) and 5(c) for hospital and ambulatory surgery center benefits).

Note:  For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children.

$15 per PCP visit

$25 per PCP visit

$55 per specialist visit

• Hearing aids as shown in Orthopedic and prosthetic devices.

All charges over $1,400/ear/every 36-month period

Note: member will be reimbursed up to the allowed amount.

All charges over $1,400/ear/every 36-month period

Note: member will be reimbursed up to the allowed amount.

Not covered:

• All other hearing testing not medically necessary
• Hearing services that are not shown as covered

• Treatment of eye diseases and injury

$15 per PCP visit

$25 per PCP visit

$55 per specialist visit

• Corrective eyeglasses and frames or contact lenses (hard or soft) for adults age 19 and older once per         24-month period.

• Corrective eyeglasses and frames or contact lenses (hard or soft)  for children through age 18 once per 24-month period.

• One (1) routine eye exam (including refraction) every 12-month period

$55 per specialist visit

Not covered:

• Fitting of contact lenses
• Vision therapy, including eye patches and eye exercises, e.g., orthoptics, pleoptics, for the treatment of conditions related to learning disabilities or developmental delays
• Radial keratotomy and laser eye surgery, including related procedures designed to surgically correct refractive errors

$15 per PCP visit

$30 per specialist visit

$25 per PCP visit

$55 per specialist visit

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open manipulation or fixation)
• Foot orthotics
• Podiatric shoe inserts

• Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes. Limb and torso prosthetics must be preauthorized.
• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

Note: Certain devices require precertification by you or your physician. Please see Section 3 for a list of services that require precertification.

Note: Coverage includes repair and replacement when due to growth or normal wear and tear.

Note:  For information on the professional charges for the surgery to insert an implant or internal prosthetic device, see Section 5(b) Surgical procedures.  For information regarding facility fees associated with obtaining orthopedic and prosthetic devices, see Section 5(c).

• Hearing aids, testing, fitting and the examination for them

Note:  Discounts on hearing exams, hearing services, and hearing aids are also available to all members.  Please see the Non-FEHB Benefits section of this brochure for more information.

• Hair prosthesis prescribed by a physician for hair loss resulting from radiation therapy, chemotherapy or certain other injuries, diseases, or treatment of a disease.

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups 
• Lumbosacral supports
• All charges over $500 for hair prosthesis 

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Contact Plan at 800-537-9384 for a complete list of covered DME. Some covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds (Clinitron and electric beds must be preauthorized)
• Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
• Crutches
• Walkers
• Insulin pumps and related supplies such as needles and catheters
• Medical foods taken for the treatment of Inborn Errors of Metabolism when provided by a participating DME provider and administered under the direction of a physician

Note: You must get your DME from a participating DME provider. Some DME may require precertification by you or your physician.

Not covered:

• Elastic stockings and support hose
• Bathroom equipment such as bathtub seats, benches, rails and lifts
• Home modifications such as stair glides, elevators and wheelchair ramps
• Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities
• Medical foods that do not require a prescription under Federal law even if your physician or other health care professional prescribes them 
• Nutritional supplements that are not administered by catheter or nasogastric tubes, except for oral medical foods taken for the treatment of Inborn Errors of Metabolism when administered under the direction of a physician

• Home health services ordered by a Plan Physician and provided by nurses and home health aides through a participating home health care agency. Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less. The plan will allow up to 60 visits per member per calendar year. Your Plan Physician will periodically review the program for continuing appropriateness and need.
• Services include oxygen therapy.

$90 per visit

$90 per visit

$30 per visit

$55 per visit

Note:  Short-term physical, speech, or occupational therapy accumulate toward the applicable benefit limit (See the physical, speech and occupational therapy benefits in this section).

Note:  Skilled nursing under home health services must be precertified by your Plan physician.

Refer to Note

Refer to Note

Not covered:

• Nursing care for the convenience of the patient or the patient’s family.
• Custodial care, i.e. home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative and appropriate for the active treatment of a condition, illness, disease or injury.
• Services provided by a family member or resident in the member’s home.
• Services rendered at any site other than the member’s home.
• Services rendered when the member is not homebound because of illness or injury.
• Private duty nursing services.
• Transportation.

Chiropractic services up to 20 visits per member per calendar year

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electric muscle stimulation, vibratory therapy and cold pack application

$15 per PCP visit

$30 per specialist visit

$25 per PCP visit

$55 per specialist visit

Not covered:

• Any services not listed above

Acupuncture - 10 visits per member per calendar year (when considered medically necessary)

Note: See Section 5(b) for our coverage of acupuncture when provided as anesthesia for covered surgery.

See Section 5 Non-FEHB benefits available to Plan members for discount arrangements.

$15 per visit

$25 per visit

Not covered:  Other alternative medical treatments including but not limited to:

• Acupuncture other than stated above
• Applied kinesiology
• Aromatherapy
• Biofeedback
• Craniosacral therapy
• Hair analysis
• Reflexology

Aetna Health Connections offers disease management for 34 conditions. Included are programs for:

• Asthma
• Cerebrovascular disease
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• Coronary artery disease
• Cystic Fibrosis
• Depression
• Diabetes
• Hepatitis
• Inflammatory bowel disease
• Kidney failure
• Low back pain
• Sickle Cell disease

To request more information on our disease management programs, call 800-537-9384.

Coverage is provided for:

• Tobacco cessation Programs including individual/group/phone counseling, and for over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence. 

Note:  OTC drugs will not be covered unless you have a prescription and the prescription is presented at the pharmacy and processed through our pharmacy claim system.

Nothing for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year.

Nothing for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.

Nothing for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year.

Nothing for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (See Reconstructive surgery)
• Surgical treatment of severe obesity (bariatric surgery) – a condition in which an individual has a body mass index (BMI) exceeding 40 or a BMI greater than 35 in conjunction with documented significant co-morbid conditions (such as coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea, nonalcoholic steatohepatitis (NASH) or refractory hypertension).**

  • Members must have attempted weight loss in the past without successful long-term weight reduction; and Members must have participated in and been compliant with an intensive multicomponent behavioral intervention through a combination of dietary changes and increased physical activity for 12 or more sessions occurring within 2 years prior to surgery. Blood glucose control must be optimized, and psychological clearance may be necessary.

We will consider:

• Open or laparoscopic Roux-en-Y gastric bypass; or
• Open or laparoscopic biliopancreatic diversion with or without duodenal switch; or
• Sleeve gastrectomy; or
• Laparoscopic adjustable silicone gastric banding (Lap-Band) procedures.

• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

• Voluntary sterilization for men (e.g., vasectomy)
• Treatment of burns
• Skin grafting and tissue implants

• Gender affirming surgery* 
  The Plan will provide coverage for the following when the member meets Plan criteria:
  - Surgical removal of breasts** 
  - Breast augmentation (implants/lipofilling)** 
  - Surgical removal of uterus, ovaries and testes**
  - Reconstruction of external genitalia**
  -Medically necessary facial gender affirming surgery and body contouring (Note: For more information on coverage details for medically necessary facial and body contouring coverage and criteria, please refer to www.aetnafeds.com/gender-affirming-care)

* Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

** Subject to medical necessity based on our clinical policy bulletin.

Note: Hormone therapy is covered under Section 5(f), Prescription drug benefits. Prior authorization is required.

$15 per PCP visit

$30 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

$25 per PCP visit

$55 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

Not covered:

• Reversal of voluntary surgically-induced sterilization
• Surgery primarily for cosmetic purposes
• Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
• Routine treatment of conditions of the foot; (see Foot care)
• Gender reassignment services that are not considered medically necessary

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital and developmental anomalies are cleft lip, cleft palate, webbed fingers and webbed toes.  All surgical requests must be preauthorized.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedema
  • breast prostheses and surgical bras and replacements (See Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

$30 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

$55 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Oral surgical procedures, that are medical in nature, such as:

• Treatment of fractures of the jaws or facial bones;
• Removal of stones from salivary ducts;
• Excision of benign or malignant lesions;
• Medically necessary surgical treatment of TMJ (must be preauthorized); 
• Excision of tumors and cysts; and 
• Removal of bony impacted wisdom teeth

Note: When requesting oral and maxillofacial services, please check our online provider directory or call Member Services at 800-537-9384 for a participating oral and maxillofacial surgeon.

$30 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

$55 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

Not covered:

• Dental implants
• Dental care (such as restorations) involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Section 3, Other services under You need prior Plan approval for certain services.

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas; Pancreas/Kidney (simultaneous)

$30 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

$55 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for:
  • AL Amyloidosis
  • High-risk neuroblastoma
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

$30 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

$55 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

Blood or marrow stem cell transplants

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells can grow. By analyzing these and other characteristics, physicians can determine which diseases will respond to treatment without transplant and which diseases may respond to transplant.

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)*
  • Hemoglobinopathies
  • Hematopoietic Stem Cell Transplant (HSCT)
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow Failure and Related Disorders (i.e. Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer*
  • Ependymoblastoma
  • Epithelial Ovarian Cancer*
  • Ewing's sarcoma
  • Hematopoietic Stem Cell Transplant (HSCT)
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
  • Waldenstrom’s macroglobulinemia

*Approved clinical trial necessary for coverage.

$30 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

$55 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP) 
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia 
• Non-myeloablative allogeneic, reduced intensity conditioning or RIC for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) 
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis 
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MPDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas 
  • Sickle Cell anemia
• Autologous Transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin's lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Scleroderma
  • Scleroderma-SSc (severe, progressive)
  • Small cell lung cancer 
  • Systemic lupus erythematosus
  • Systemic sclerosis

$30 per specialist visit

$55 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

• National Transplant Program (NTP) - Transplants which are non-experimental or non-investigational are a covered benefit. Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery. The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures. A transplant is non-experimental and non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate treatment for your specific condition. Coverage for a transplant where you are the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.

*Note: Transplants must be performed at hospitals designated as Institutes of Excellence (IOE). Hospitals in our network, but not designated as an IOE hospital will not be covered.

Refer to Note

Refer to Note

Refer to Note

Refer to Note

Clinical trials must meet the following criteria:

A. The member has a current diagnosis that will most likely cause death within one year or less despite therapy with currently accepted treatment; or the member has a diagnosis of cancer; AND

B. All of the following criteria must be met:

1. Standard therapies have not been effective in treating the member or would not be medically appropriate; and

2. The risks and benefits of the experimental or investigational technology are reasonable compared to those associated with the member's medical condition and standard therapy based on at least two documents of medical and scientific evidence (as defined below); and

3. The experimental or investigational technology shows promise of being effective as demonstrated by the member’s participation in a clinical trial satisfying ALL of the following criteria:

a. The experimental or investigational drug, device, procedure, or treatment is under current review by the FDA and has an Investigational New Drug (IND) number; and

b. The clinical trial has passed review by a panel of independent medical professionals (evidenced by Aetna’s review of the written clinical trial protocols from the requesting institution) approved by Aetna who treat the type of disease involved and has also been approved by an Institutional Review Board (IRB) that will oversee the investigation; and

c. The clinical trial is sponsored by the National Cancer Institute (NCI) or similar national cooperative body (e.g., Department of Defense, VA Affairs) and conforms to the rigorous independent oversight criteria as defined by the NCI for the performance of clinical trials; and

d. The clinical trial is not a single institution or investigator study (NCI designated Cancer Centers are exempt from this requirement); and

4. The member must:

a. Not be treated “off protocol,” and

b. Must actually be enrolled in the trial.

$30 per specialist visit

$55 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

Not covered:

Professional services (including Acupuncture - when provided as anesthesia for a covered surgery) provided in:

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

Note: For sedation or anesthesia relating to dental services performed in a dental office, see Section 5(g), Dental benefits.

Note: When the anesthesiologist is the primary giver of services, such as for pain management, the specialist copay applies.

Room and board, such as

• Private, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Blood products, derivatives and components, artificial blood products and biological serum. Blood products include any product created from a component of blood such as, but not limited to, plasma, packed red blood cells, platelets, albumin, Factor VIII, Immunoglobulin, and prolastin
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

$150 per day up to a maximum of $450 per admission

20% of plan allowance per admission

Not covered:

• Whole blood and concentrated red blood cells not replaced by the member
• Non-covered facilities, such as nursing homes, schools
• Custodial care, rest cures, domiciliary or convalescent cares
• Personal comfort items, such as phone and television
• Private nursing care

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Radiologic procedures, diagnostic laboratory tests, and X-rays when associated with a medical procedure being done the same day
• Pathology Services
• Administration of blood, blood plasma, and other biologicals
• Blood products, derivatives and components, artificial blood products and biological serum
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service 
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal. 

Note: Certain devices require precertification by you or your physician. Please see Section 3 for a list of services that require precertification.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Note:  Preventive care services are not subject to copays listed.

$350 per visit

Services not associated with a medical procedure being done the same day, such as:

• Mammogram  
• Radiologic procedures*
• Lab tests*
• Sleep Studies

*See below for exceptions

Note:  Preventive care services are not subject to copays listed.

$55 per specialist visit

Complex diagnostic tests limited to:

• Bone density tests - diagnostic
• CT scans/MRIs/PET scans
• Diagnostic angiography
• Genetic testing - diagnostic*
• Nuclear medicine

Note: These services need precertification. See "Services requiring our prior approval" in Section 3.

* Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient's medical condition.

$100 copay

Not covered: Whole blood and concentrated red blood cells not replaced by the member.

$5 copay

$5 copay

Aetna covers ground ambulance from the place of injury or illness to the closest facility that can provide appropriate care. The following circumstances would be covered:

1. Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or 
2. To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or
3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

Ambulance - $100 copay

Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day.

Ambulance - $100 copay

Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day.

Not covered:

• Ambulance transportation to receive outpatient or inpatient services and back home again, except in an emergency
• Ambulette service
• Ambulance transportation for member convenience or reasons that are not medically necessary

Note:  Elective air ambulance transport, including facility-to-facility transfers, requires prior approval from the Plan.

• Emergency or urgent care at a doctor’s office

$15 per PCP visit

$30 per specialist visit

$25 per PCP visit

$55 per specialist visit

• Services provided at a Walk in clinic or CVS MinuteClinic®

$0 per visit

$0 per visit

• Emergency or urgent care at an urgent care center

• Emergency or urgent care as an outpatient at a hospital (Emergency Room) including doctors' services.

$125 per visit

Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

$200 per visit

Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

All charges

• Emergency or urgent care at a doctor’s office

$55 per specialist visit

• Services provided at a Walk in clinic or CVS MinuteClinic®

$0 per visit

$0 per visit

• Emergency or urgent care at an urgent care center

• Emergency or urgent care as an outpatient at a hospital (Emergency Room), including doctors' services.

$125 per visit

Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

$200 per visit

Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.

• Teladoc Health® consult

$30 per consult

$40 per consult

• CVS Health Virtual Care™ consult

$0 per consult

$0 per consult

Please see www.aetnafed.com/tools.php for information on medical and behavioral telehealth services.
Members will receive a welcome kit explaining the telehealth benefits.
Refer to Section 5(e) for behavioral health telehealth consults.

Aetna covers ground ambulance from the place of injury or illness to the closest facility that can provide appropriate care. The following circumstances would be covered:

1. Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or

2. To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or

3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or

4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

Air and sea ambulance may be covered. Prior approval is required.

Note: See 5(c) for non-emergency service.

Ambulance - $100 copayment

Air/Sea ambulance - $150 copayment

Ambulance - $100 copayment

Air/Sea ambulance - $150 copayment

Not covered:

• Ambulance transportation to receive outpatient or inpatient services and back home again, except in an emergency.
• Ambulette service
• Air ambulance without prior approval
• Ambulance transportation for member convenience or for reasons that are not medically necessary.

Note:  Elective air ambulance transport, including facility-to-facility transfers, requires prior approval from the Plan.

We cover professional services by licensed professional mental health and substance misuse disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

• Psychiatric office visits to Behavioral Health practitioner
• Substance Use Disorder (SUD) office visits to Behavioral Health practitioner
• Routine psychiatric office visits to Behavioral Health practitioner
• Behavioral therapy

$55 per visit

Telehealth Behavioral Health consult

$30 per consult

$55 per consult

CVS Health Virtual Care™ telehealth consult

$30 per consult

$55 per consult

• Skilled behavioral health services provided in the home, but only when all of the following criteria are met:
  • Your physician orders them
  • The services take the place of a stay in a hospital or a residential treatment facility, or you are unable to receive the same services outside your home
  • The skilled behavioral health care is appropriate for the active treatment of a condition, illness or disease to avoid placing you at risk for serious complications

$30 per visit

$55 per visit

Applied Behavior Analysis (ABA)

The plan covers medically necessary Applied Behavior Analysis (ABA) therapy when provided by network behavioral health providers. These providers include:

• Providers who are licensed or who possess a state-issued or state-sanctioned certification in ABA therapy.
• Behavior analysts certified by the Behavior Analyst Certification Board (BACB).
• Registered Behavior Technicians (RBTs) certified by the BACB or equivalent paraprofessionals who work under the supervision of a licensed provider or a certified behavior analyst.

Note: Requires Precertification. See Section 3 “Services requiring our prior approval”.  You are responsible for ensuring that we are asked to precertify your care.  You should always ask your physician or hospital whether they have contacted us.  For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

$55 per visit

• Psychological and Neuropsychological testing tests provided and billed by a licensed mental health and SUD treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

$55 per outpatient visit

Inpatient services provided and billed by a hospital or other covered facility including an overnight residential treatment facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

20% of plan allowance per admission

Outpatient services provided and billed by a hospital or other covered facility including other outpatient mental health treatment such as:

• Partial hospitalization treatment provided in a facility or program for mental health treatment provided under the direction of a physician
• Intensive outpatient program provided in a facility or program for mental health treatment provided under the direction of a physician
• Outpatient detoxification
• Ambulatory detoxification which is outpatient services that monitor withdrawal from alcohol or other substance abuse, including administration of medications
• Electro-convulsive therapy (ECT)
• Transcranial magnetic stimulation (TMS)
• Psychological/Neuropsychological testing

$55 per outpatient visit

• Educational services for treatment of behavioral disorders
• Services in half-way houses

We cover the following medications and supplies prescribed by a licensed physician or dentist and obtained from a Plan pharmacy or through our mail order program:

• Drugs approved by the U.S. Food and Drug Administration for which a prescription is required by Federal law, except those listed as Not covered
• Diabetic supplies limited to
  • Lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips
  • Insulin
  • Disposable needles and syringes needed to inject covered prescribed medications
• Prenatal vitamins (as covered under the plan's formulary)
• Drugs to treat gender dysphoria
• Oral and Injectable Infertility medications (Includes Artificial Insemination (AI), In vitro fertilization (IVF)/ART medications) 

Note: If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained.

Note: Certain drugs to treat Gender dysphoria and infertility are considered specialty drugs. Please see Specialty drugs in this section.

Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

$3 per Preferred Generic (PG) formulary drug;

$35 per Preferred Brand (PB) name formulary drug; and

50% up to $200 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

$6 (two copays) per Preferred Generic (PG) formulary drug;

$70 (two copays) per Preferred Brand (PB) name formulary drug; and

50% up to $400 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

$10 per  Preferred Generic (PG) formulary drug;

50% up to $200 maximum per Preferred Brand (PB) name formulary drug; and

50% up to $300 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

$20 (two copays) per Preferred Generic (PG) formulary drug;

50% up to $400 maximum per Preferred Brand (PB) name formulary drug; and

50% up to $600 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Preventive Care Medications

Medications to promote better health as recommended by ACA.

Drugs and supplements are covered without cost-share, which includes some over-the-counter, when prescribed by a health care professional and filled at a network pharmacy.

We will cover preventive medications in accordance with the U.S. Preventive Services Task Force (USPSTF) recommendations/guidance:

• Aspirin
• Folic acid supplements
• Oral fluoride
• Statins
• Breast cancer prevention drugs
• HIV PrEP
• Nicotine Replacement Medications (Limits apply)
• Bowel Prep Medications (Required with preventive Colonoscopy)

Please refer to the Aetna formulary guide for a complete list of preventive drugs including coverage details and limitations: www.aetnafeds.com/pharmacy.php

Note: To receive this benefit a prescription from a doctor must be presented to pharmacy.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy. These may include some over-the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to
www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.

Women's contraceptive drugs and devices

• Generic oral contraceptives on our formulary list
• Generic emergency contraception, including over-the-counter (OTC) when filled with a prescription
• Generic injectable contraceptives on our formulary list - five (5) vials per calendar year
• Diaphragms - one (1) per calendar year
• Brand name Intra Uterine Device
• Generic patch contraception

Note: If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at
www.aetnafeds.com/pharmacy.php to review our 2024 Pharmacy Drug (Formulary) Guide or call 800-537-9384.

• Brand name contraceptive drugs
• Brand name injectable contraceptive drugs such as Depo Provera - five (5) vials per calendar year
• Brand emergency contraception 

Note:  If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained.

Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

$35 per Preferred Brand (PB) name formulary drug; and

50% up to $200 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

$70 (two copays) per Preferred Brand (PB) name formulary drug; and

50% up to $400 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

50% up to $200 maximum per Preferred Brand (PB) name formulary drug; and

50% up to $300 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

50% up to $400 maximum per Preferred Brand (PB) name formulary drug; and

50% up to $600 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Specialty Medications

Specialty medications must be filled through a network specialty pharmacy.  These medications are not available through the mail order benefit.

Certain Specialty Formulary medications identified on the Specialty Drug List next to the drug name may be covered under the medical or pharmacy section of this brochure. Please refer to above, Specialty Drugs for more information or visit www.aetnafeds.com/pharmacy.php

Up to a 30-day supply per prescription or refill:

Preferred Specialty (PSP): 50% up to $350 maximum

Non-preferred Specialty (NPSP): 50% up to $700 maximum

Up to a 30-day supply per prescription or refill:

Preferred Specialty (PSP): 50% up to $350 maximum

Non-preferred Specialty (NPSP): 50% up to $700 maximum

Limited benefits:

• Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period.  Contact the Plan at 800-537-9384 for dose limits.

Retail Pharmacy for up to a 30-day supply per prescription or refill:

$3 per Preferred Generic (PG) formulary drug;

$35 per Preferred Brand (PB) name formulary drug; and

50% up to $200 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Retail Pharmacy for up to a 30-day supply per prescription or refill:

$10 per Preferred Generic (PG) formulary drug;

50% up to $200 maximum per Preferred Brand (PB) name formulary drug; and

50% up to $300 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

Not covered:

• Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law.
• Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
• Vitamins, unless otherwise stated (including prescription vitamins), nutritional supplements, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition when administered under the direction of a Plan doctor (please see Durable Medical Equipment in Section 5(a) for more information on what the plan will cover).
• Medical supplies such as dressings and antiseptics
• Lost, stolen or damaged drugs
• Drugs for cosmetic purposes
• Drugs to enhance athletic performance
• Nonprescription medications unless specifically indicated elsewhere
• Prophylactic drugs including, but not limited to, anti-malarials for travel
• Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
• Compounded thyroid hormone therapy

Note:  Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See Section 5(a)).  OTC drugs will not be covered unless you have a prescription and that prescription is presented at the pharmacy and processed through our pharmacy claim system.

All charges

All charges

We cover the following medications and supplies prescribed by a licensed physician or dentist and obtained from a Plan pharmacy or through our mail order program:

This prescription drug plan offers the Comprehensive Plus formulary which covers all drugs that CMS determines to be Part D and additionally, offers supplemental benefits for coverage of non-Part D drugs as outlined below.

For access to our formulary, please visit:
www.aetnafeds.com/pharmacy 

Non-Part D Supplemental Benefit:

• Agents used for cosmetic purposes or hair growth.
• Agents used to promote fertility.
• Agents when used for the symptomatic relief of cough and colds.
• Agents when used for the treatment of sexual or erectile dysfunction (ED).
• Agents when used for weight loss.
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
• Part B drugs.

Retail Pharmacy, for up to a 30-day supply per prescription or refill:

• Tier 1 Preferred Generic: $0 per drug at preferred/standard pharmacy;
• Tier 2 Generic: $2 per drug at preferred pharmacy; $3 per drug at standard pharmacy;
• Tier 3 Preferred Brand: $25 per drug at preferred/standard pharmacy;
• Tier 4 Non-Preferred Brand: $75 per drug at preferred/standard pharmacy;
• Tier 5 Specialty (Includes high-cost/unique generic and brand drugs): 25%, but not more than $150 per drug at preferred/standard pharmacy;

Retail/Mail Order Pharmacy, for up to a 90-day supply per prescription or refill:

• Tier 1 Preferred Generic: $0 per drug at preferred/standard pharmacy;
• Tier 2 Generic: $4 per drug at preferred pharmacy; $6 per drug at standard pharmacy;
• Tier 3 Preferred Brand: $50 per drug at preferred/standard pharmacy;
• Tier 4 Non-Preferred Brand: $150 per drug at preferred/standard pharmacy;
• Tier 5 Specialty: only available for 30 day supply

Retail Pharmacy, for up to a 30-day supply per prescription or refill:

• Tier 1 Preferred Generic: $0 per drug at preferred/standard pharmacy;
• Tier 2 Generic: $4 per drug at preferred pharmacy; $5 per drug at standard pharmacy;
• Tier 3 Preferred Brand: $40 per drug at preferred/standard pharmacy;
• Tier 4 Non-Preferred Brand: $100 per drug at preferred/standard pharmacy;
• Tier 5 Specialty (Includes high-cost/unique generic and brand drugs): 25%, but not more than $150 per drug at preferred/standard pharmacy;

Retail/Mail Order Pharmacy, for up to a 90-day supply per prescription or refill:

• Tier 1 Preferred Generic: $0 per drug at preferred/standard pharmacy;
• Tier 2 Generic: $8 per drug at preferred pharmacy; $10 per drug at standard pharmacy;
• Tier 3 Preferred Brand: $80 per drug at preferred/standard pharmacy;
• Tier 4 Non-Preferred Brand: $200 per drug at preferred/standard pharmacy;
• Tier 5 Specialty: only available for 30 day supply

• Preventive drugs that are part of the Affordable Care Act. (A valid prescription is required.)
• Narcan
• Select drugs to treat cancer
• Includes coverage of Part B covered diabetic supplies and vaccines
• Tobacco Cessation drugs

$0

$0

Medicare Part D Prescription Drug Plan – EGWP PDP includes a maximum out of pocket.

Note: Once you reach the $2,000 out of pocket maximum for your prescription costs, you will pay $0 for the remainder of the calendar year for covered drugs under this Medicare Part D Prescription Drug Plan. This $2,000 will also apply to the Medical Plan’s total calendar year out-of-pocket maximum, see Section 4 for additional details on your Plan option out of pocket maximum.

$2,000

$2,000

Coverage is limited to palliative treatment and those services listed on the following schedule.

Note: See Oral and maxillofacial surgery, section 5(b).

Annual Deductible

$20 per member per year.

$20 per member per year.

Diagnostic

Office visit for routine oral evaluation — limited to 2 visits per year

Bitewing X-rays — limited to 2 sets of bitewing  X-rays per year

Complete X-ray series — limited to 1 complete X-ray series in any 3 year period

Periapical X-rays and other dental X-rays — as necessary

Diagnostic casts

Preventive

Prophylaxis (cleaning of teeth) — limited to 2 treatments per year

Topical application of fluoride — limited to 2 courses of treatment per year to children under age 18

Oral hygiene instruction (not covered under PPO)

Restorative (Fillings)

Amalgam/Composite 1 surface, primary or permanent

Amalgam/Composite 2 surfaces, primary or permanent

Amalgam/Composite 3 surfaces, primary or permanent

Amalgam/Composite 4 or more surfaces, primary or permanent

Prosthodontics Removable

Denture adjustments (complete or partial/upper or lower)

Endodontics

Pulp cap — direct

Pulp cap — indirect

No deductible:

$5 per visit

Professional services of physicians (PCP or Specialist)

• In physician’s office
• Office medical evaluations, examinations, and consultations
• Second surgical or medical opinion

30% of our plan allowance

• During a hospital stay
• In a skilled nursing facility

30% of our plan allowance

• In an urgent care center

30% of our plan allowance

• At home

30% of our plan allowance

• Teladoc Health® consult 

30% of the consult fee

• CVS Health Virtual Care™ consult

$55 per consult until the deductible is met, $0 per consult after deductible has been met

Please see www.aetnafeds.com/tools.php for information on medical and behavioral telehealth services.

Members will receive a welcome kit explaining the telehealth benefits.

Refer to Section 5(e) for behavioral health telehealth consults.

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and electroencephalogram (EEG)
• Sleep Studies

30% of our plan allowance

Diagnostic tests limited to:

• Bone density tests - diagnostic
• CT scans/MRIs/PET scans
• Diagnostic angiography
• Genetic testing - diagnostic*
• Nuclear medicine

 Note: The services need precertification. See Section 3 "Services requiring our prior approval".

*Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient's medical condition.

30% of our plan allowance

• Genetic Counseling and Evaluation for BRCA Testing
• Genetic Testing for BRCA-Related Cancer* 

*Note: Requires precertification. See Section 3 "Services requiring our prior approval".

Nothing (no deductible)

• Routine physicals - one (1) exam every calendar year 

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://shorturl.at/hovHM. 
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at 
  https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder
• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

Note: Some tests provided during a routine physical may not be considered preventive. Contact member services at 800-537-9384 for information on whether a specific test is considered routine.

Nothing (no deductible)

Routine mammogram - covered

• One (1) every calendar year; or when medically necessary

Nothing (no deductible)

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Nothing (no deductible)

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing (no deductible)

Not covered:

• Physical exams, immunizations, and boosters required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to 
  https://brightfutures.aap.org
• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at 
  https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://shorturl.at/hovHM. 
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Note: Some tests provided during a routine physical may not be considered preventive. Contact member services at 800-537-9384 for information on whether a specific test is considered routine.

Nothing (no deductible)

• Well-child care charges for routine examinations, immunizations and care (up to age 22)
• Seven (7) routine exams to from birth age 12 months
• Three (3) routine exams from age 12 months to 24 months
• Three (3) routine exams from age 24 months to 36 months
• One (1) routine exam per year thereafter to age 22
• Examinations such as:
  • Vision screenings through age 17 to determine the need for vision correction*
  • Hearing exams through age 17 to determine the need for hearing correction
  • Routine examinations done on the day of immunizations (up to age 22)

*For routine eye refraction, see Vision Services

Nothing (no deductible)

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Refer to Note

Not covered:

• Physical exams, immunizations and boosters required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

All charges

Complete maternity (obstetrical) care, such as:

• Routine Prenatal care - includes the initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. 
• Screening and counseling for prenatal and postpartum depression

Note: Items not considered routine include: (but not limited to)

• Amniocentesis
• Certain Pregnancy diagnostic lab tests
• Delivery including Anesthesia
• Fetal Stress Tests
• High Risk Specialist Visits
• Inpatient admissions
• Ultrasounds
• Screening for gestational diabetes
• Delivery
• Postnatal care

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will extend your inpatient stay if medically necessary, but you, your representative, your participating doctor, or your hospital must precertify the extended stay.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay including the initial examination of a newborn child covered under a Self Only, Self Plus One or Self and Family enrollment. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for maternity care (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

Note: Also see our Enhanced Maternity Program in Section 5 (h).

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Nothing (no deductible) for routine prenatal care or the first postpartum care visit when services are rendered by an in-network delivering health care provider, 30% of our Plan allowance for postpartum care visits thereafter.

Note: If your PCP or specialist refers you to another specialist or facility for additional services, you pay the applicable cost share for the service rendered.

Breastfeeding support, supplies and counseling for each birth

Nothing (no deductible)

Not covered: Home births

All charges

A range of voluntary family planning services limited to:

• Contraceptive counseling on an annual basis
• Surgically implanted contraceptives
• Generic injectable contraceptive drugs, such as Depo-Provera
• Intrauterine devices (IUDs)
• Diaphragms
• Tubal ligation

Note: We cover injectable contraceptives under the medical benefit when supplied by and administered at the provider's office. Injectable contraceptives are covered at the prescription drug benefit when they are dispensed at the Pharmacy. If a member must obtain the drug at the pharmacy and bring it to the provider's office to be administered, the member would be responsible for both the Rx and office visit cost sharing. We cover oral contraceptives under the prescription drug benefit.

Nothing (no deductible)

• Voluntary sterilization (See Surgical procedures Section 5 (b))

Nothing (no deductible) for women

For men: 30% of our plan allowance

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

All charges

Infertility is a disease defined as when a person is unable to conceive or produce conception after one year of egg-sperm contact when the individual attempting conception is under 35 years of age, or after six months of egg-sperm contact when the individual attempting conception is 35 years of age or older.  Egg-sperm contact can be achieved by regular sexual intercourse or artificial insemination (intrauterine, intracervical, or intravaginal) as stated in our medical clinical policy bulletin (see Section 10. for definition of Medical Necessity for additional details on Aetna’s Clinical Policy).  This definition applies to all individuals regardless of sexual orientation or the presence/availability of a reproductive partner.  Infertility may also be established by the demonstration of a disease or condition of the reproductive tract such that egg-sperm contact would be ineffective.

Diagnosis and treatment of infertility, such as:

• Testing for diagnosis and surgical treatment of the underlying medical cause of infertility.
• Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease.* **

Comprehensive Infertility Services

• Artificial insemination (AI)* ** and monitoring of ovulation:
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
  • Intravaginal insemination (IVI)

Note: We limit Artificial Insemination to 3 cycles per calendar year. The Plan defines a “cycle” as:

• An attempt at ovulation induction while on injectable medication to stimulate the ovaries with or without artificial insemination
• An artificial insemination cycle with or without injectable medication to stimulate the ovaries
• Ovulation induction cycle(s) while on injectable medication to stimulate the ovaries. *
• Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician *
• Injectable fertility drugs including but not limited to menotropins, hCG, GnRH agonists, and intravenous immunoglobulins (IVIG). (See Section 5f for coverage)*

You are eligible for these covered services if:

• You or your partner have been diagnosed with infertility.
• You have met the requirement for the number of months trying to conceive through egg and sperm contact.
• Your unmedicated day 3 Follicle Stimulating Hormone (FSH) level and testing of ovarian responsiveness meet the criteria outlined in Aetna’s infertility clinical policy.

Note: The Plan does not cover infertility drugs under the medical benefit. See Section 5(f) for coverage.

 Aetna’s National Infertility Unit

Our NIU is here to help you and is staffed by a dedicated team of registered nurses and infertility coordinators. They can help you with understanding your benefits and the medical precertification process. You can learn more at www.aetnainfertilitycare.com or call the NIU at 1-800-575-5999  (TTY: 711).

* Subject to medical necessity

** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384. Your network provider will request approval from us in advance for your infertility services. If your provider is not a network provider, you are responsible to request approval from us in advance.

50% of our plan allowance

Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See  Section 4 for details)

Not covered:

All infertility services associated with or in support of an Advanced Reproductive Technology (ART) cycle. These include, but are not limited to:

• Imaging, laboratory services, and professional services
• In vitro fertilization (IVF)
• Zygote intrafallopian transfer (ZIFT)
• Gamete intrafallopian transfer (GIFT)
• Cryopreserved embryo transfers
• Gestational carrier cycles
• Any related services, products or procedures (such as intracytoplasmic sperm injection (ICSI) or ovum microsurgery).

• Cryopreservation (freezing), storage or thawing of eggs, embryos, sperm or reproductive tissue (unless noted as covered)
• All charges associated with or in support of surrogacy arrangements for you or the surrogate. A surrogate is a female carrying her own genetically related child with the intention of the child being raised by someone else, including the biological father
• Infertility services that are not reasonably likely to result in success
• Any charges associated with care required to obtain ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for ART procedures except as stated above
• The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers (or surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational carrier
• Reversal of sterilization surgery.
• Treatment for infertility when the cause of the infertility was a previous sterilization with or without surgical reversal. This includes tubal ligation, hysterectomy and vasectomy only if obtained as a form of voluntary sterilization
• Services and supplies related to the above mentioned services, including sperm processing
• Cost of home ovulation predictor kits or home pregnancy kits
• Drugs related to the treatment of non-covered benefits
• Infertility services that are not reasonably likely to result in success
• Elective fertility preservation, such as egg freezing sought due to natural aging;
• Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention
• Storage costs
• Obtaining sperm from a person not covered under this plan
• Infertility treatment when a successful pregnancy could have been obtained through less costly treatment
• Infertility treatment when infertility is due to a natural physiologic process such as age related ovarian insufficiency (e.g. perimenopause, menopause)as measured by an unmedicated FSH level at or above 19 on cycle day two or three of your menstrual period or other abnormal testing results as outlined in Aetna’s infertility clinical policy
• Oral and Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH agonists. (except where otherwise noted in Section 5f)
• Any infertility service rendered that requires precertification without a prior authorization
• Coverage for services received by a spouse or partner who is not a covered member under the plan

All charges

• Testing and treatment
• Allergy injections 

Note: You pay the applicable cost share for each visit to a doctor’s office including each visit to a nurse for an injection.

30% of our plan allowance

Allergy serum

30% of our plan allowance

Not covered: Provocative food testing and sublingual allergy desensitization

All charges

• Chemotherapy and radiation therapy 

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants in Section 5(b).

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis 
• Intravenous (IV) Infusion Therapy in a doctor’s office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services.)
• Growth hormone therapy (GHT) 

Note: Growth hormone therapy is covered under Medical Benefits; office cost sharing applies. We cover growth hormone injectables under the prescription drug benefit.

Note: We will only cover GHT when we preauthorize the treatment. Call 800-245-1206 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information and it is authorized by Aetna. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Applied Behavior Analysis - (see Section 5(e) for benefits)

30% of our plan allowance

60 visits per person, per calendar year for physical or occupational therapy or a combination of both for the services of each of the following:

• Qualified Physical therapists
• Occupational therapists 

Note: We only cover therapy when a physician:

• Orders the care;
• Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• Indicates the length of time the services are needed.

Note: Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living. Inpatient therapy is covered under Hospital/ Extended Care Benefits.

• Physical therapy to treat temporomandibular joint (TMJ) pain dysfunction syndrome 

Note: Physical therapy treatment of lymphedemas following breast reconstruction surgery is covered under the Reconstructive surgery benefit - see section 5(b).

30% of our plan allowance

Not covered:

• Long-term rehabilitative therapy

All charges

• Twenty visits per condition per member per calendar year of pulmonary rehabilitation to treat functional pulmonary disability
• Cardiac rehabilitation following a qualifying event/ condition is provided for up to 3 visits a week for a total of 18 visits.

30% of our plan allowance

Not Covered: Long-term rehabilitative therapy

All charges

• Habilitative services for children under age 19 with congenital or genetic birth defects including, but not limited to, autism or an autism spectrum disorder and developmental delays. Treatment is provided to enhance the child's ability to function. Services include occupational therapy, physical therapy and speech therapy. 

Note: No day or visit limit applies.

30% of our plan allowance

60 visits per person, per calendar year

Note: For children up to age 19, no day or visit limit applies for habilitative therapy, see section 5(a) Habilitative therapy.

30% of our plan allowance

• Audiological testing and medically necessary treatment for hearing problems
• Hearing testing for children through age 17 (See Preventive care, children)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants (See Orthopedic and prosthetic devices section and the note referring to Section 5(b) and 5 (c) for hospital and ambulatory surgery center benefits). 

Note: For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children.

30% of our plan allowance

Not covered:

• All other hearing testing not medically necessary
• Hearing services that are not shown as covered
• Hearing aids

All charges

• Treatment of eye diseases and injury

30% of our plan allowance

• One (1) routine eye exam (including refraction) every 12-month period 

30% of our plan allowance

Not covered:

• Fitting of contact lenses
• Vision therapy, including eye patches and eye exercises, e.g., orthoptics, pleoptics, for the treatment of conditions related to learning disabilities or developmental delays
• Radial keratotomy and laser eye surgery, including related procedures designed to surgically correct refractive errors

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

30% of our plan allowance

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open manipulation or fixation)
• Foot orthotics
• Podiatric shoe inserts

All charges

• Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes. Limb and torso prosthetics must be preauthorized.
• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.) 

Note: Certain devices require precertification by you or your physician. Please see Section 3 for a list of services that require precertification.

Note: Coverage includes repair and replacement when due to growth or normal wear and tear.

Note: For information on the professional charges for the surgery to insert an implant or internal prosthetic device, see Section 5(b) Surgical procedures. For information regarding facility fees associated with obtaining orthopedic and prosthetic devices, see Section 5(c).

30% of our plan allowance

• Hair prosthesis prescribed by a physician for hair loss resulting from radiation therapy, chemotherapy or certain other injuries, diseases, or treatment of a disease.

Nothing up to Plan lifetime maximum of $500

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• All charges over $500 for hair prosthesis

All charges

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Contact Plan at 800-537-9384 for a complete list of covered DME. Some covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds (Clinitron and electric beds must be preauthorized)
• Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
• Crutches
• Walkers
• Insulin pumps and related supplies such as needles and catheters
• Medical foods taken for the treatment of Inborn Errors of Metabolism when provided by a participating DME provider and administered under the direction of a physician

Note: You must get your DME from a participating DME provider. Some DME may require precertification by you or your physician.

30% of our plan allowance

Not covered:

• Elastic stockings and support hose
• Bathroom equipment such as bathtub seats, benches, rails and lifts
• Home modifications such as stair glides, elevators and wheelchair ramps
• Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities
• Medical foods that do not require a prescription under Federal law even if your physician or other health care professional prescribes them 
• Nutritional supplements that are not administered by catheter or nasogastric tubes, except for oral medical foods taken for the treatment of Inborn Errors of Metabolism when administered under the direction of a physician

All charges

• Home health services ordered by a Plan Physician and provided by nurses and home health aides through a participating home health care agency. Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less. The plan will allow up to 60 visits per member per calendar year. Your Plan Physician will periodically review the program for continuing appropriateness and need.
• Services include oxygen therapy.

30% of our plan allowance

Intravenous (IV) Infusion Therapy and medications

30% of our plan allowance

Note: Short-term physical, speech, or occupational therapy accumulate toward the applicable benefit limit (See the physical, speech and occupational therapy benefits in this section).

Note: Skilled nursing under home health services must be precertified by your Plan physician.

Not covered:

• Nursing care for the convenience of the patient or the patient’s family.
• Custodial care, i.e. home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative and appropriate for the active treatment of a condition, illness, disease or injury.
• Services provided by a family member or resident in the member’s home.
• Services rendered at any site other than the member’s home.
• Services rendered when the member is not homebound because of illness or injury.
• Private duty nursing services.
• Transportation.

All charges

Chiropractic services up to 20 visits per member per calendar year

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electric muscle stimulation, vibratory therapy and cold pack application

30% of our plan allowance

Not covered:

• Any services not listed above

All charges

Acupuncture - 10 visits per member per calendar year (when considered medically necessary)

Note: See Section 5(b) for our coverage of acupuncture when provided as anesthesia for covered surgery.

See Section 5 Non-FEHB benefits available to Plan members for discount arrangements.

30% of plan allowance (after deductible)

Not covered: Other alternative medical treatments including but not limited to:

• Acupuncture other than stated above
• Applied kinesiology
• Aromatherapy
• Biofeedback
• Craniosacral therapy
• Hair analysis
• Reflexology

All charges

Aetna Health Connections offers disease management for 34 conditions. Included are programs for:

• Asthma
• Cerebrovascular disease
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• Coronary artery disease
• Cystic Fibrosis
• Depression
• Diabetes
• Hepatitis
• Inflammatory bowel disease
• Kidney failure
• Low back pain
• Sickle Cell disease

To request more information on our disease management programs, call 800-537-9384.

Nothing (no deductible)

Coverage is provided for:

• Tobacco cessation Programs including individual/ group/phone counseling, and for over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence.

Note: OTC drugs will not be covered unless you have a prescription and the prescription is presented at the pharmacy and processed through our pharmacy claim system.

Nothing (no deductible) for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year.

Nothing for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (See Reconstructive surgery)
• Surgical treatment of severe obesity (bariatric surgery) – a condition in which an individual has a body mass index (BMI) exceeding 40 or a BMI greater than 35 in conjunction with documented significant co-morbid conditions (such as coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea, nonalcoholic steatohepatitis (NASH) or refractory hypertension).**

  • Members must have attempted weight loss in the past without successful long-term weight reduction; and Members must have participated in and been compliant with an intensive multicomponent behavioral intervention through a combination of dietary changes and increased physical activity for 12 or more sessions occurring within 2 years prior to surgery. Blood glucose control must be optimized, and psychological clearance may be necessary.

We will consider:

• Open or laparoscopic Roux-en-Y gastric bypass; or
• Open or laparoscopic biliopancreatic diversion with or without duodenal switch; or
• Sleeve gastrectomy; or
• Laparoscopic adjustable silicone gastric banding (Lap-Band) procedures.

• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

• Voluntary sterilization for men (e.g., vasectomy)
• Treatment of burns
• Skin grafting and tissue implants
• Gender affirming surgery*

The Plan will provide coverage for the following when the member meets Plan criteria:

- Surgical removal of breasts** 
- Breast augmentation (implants/lipofilling)** 
- Surgical removal of uterus, ovaries and testes** 
- Reconstruction of external genitalia**
-Medically necessary facial gender affirming surgery and body contouring (Note: For more information on coverage details for medically necessary facial and body contouring coverage and criteria, please refer to www.aetnafeds.com/gender-affirming-care)

* Note: Requires Precertification. See Section 3 “Services requiring our prior approval”.  You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

** Subject to medical necessity based on our clinical policy bulletin.

Note: Hormone therapy is covered under Section 5(f), Prescription drug benefits. Prior authorization is required.

30% of our Plan allowance

Voluntary sterilization for women (e.g., tubal ligation)

Nothing (no deductible)

Not covered:

• Reversal of voluntary surgically-induced sterilization
• Surgery primarily for cosmetic purposes
• Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
• Routine treatment of conditions of the foot; (see Foot care)
• Gender reassignment services that are not considered medically necessary

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital and developmental anomalies are cleft lip, cleft palate, webbed fingers and webbed toes. All surgical requests must be preauthorized.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedema
  • breast prostheses and surgical bras and replacements (See Prosthetic devices)

 Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

30% of our Plan allowance

Not covered:

Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

All charges

Oral surgical procedures, that are medical in nature, such as:

• Treatment of fractures of the jaws or facial bones;
• Removal of stones from salivary ducts;
• Excision of benign or malignant lesions;
• Medically necessary surgical treatment of TMJ (must be preauthorized);
• Excision of tumors and cysts; and
• Removal of bony impacted wisdom teeth

 Note: When requesting oral and maxillofacial services, please check our online provider directory or call Member Services at 800-537-9384 for a participating oral and maxillofacial surgeon.

30% of our Plan allowance

Not covered:

• Dental implants
• Dental care (such as restorations) involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Section 3, Other services under You need prior Plan approval for certain services.

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas; Pancreas/Kidney (simultaneous)

30% of our Plan allowance

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for:
  • AL Amyloidosis
  • High-risk neuroblastoma
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

30% of our Plan allowance

Blood or marrow stem cell transplants

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells can grow. By analyzing these and other characteristics, physicians can determine which diseases will respond to treatment without transplant and which diseases may respond to transplant.

30% of our Plan allowance

The Plan extends coverage for the diagnoses as indicated below.

• Allogenic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  •  Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)*
  • Hemoglobinopathies
  • Hematopoietic Stem Cell Transplant (HSCT)
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow Failure and Related Disorders (i.e. Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer*
  • Ependymoblastoma
  • Epithelial Ovarian Cancer*
  • Ewing's sarcoma
  • Hematopoietic Stem Cell Transplant (HSCT)
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
  • Waldenstrom’s macroglobulinemia

*Approved clinical trial necessary for coverage.

30% of our Plan allowance

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Non-myeloablative allogeneic, reduced intensity conditioning or RIC for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MPDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle Cell anemia
• Autologous Transplants for:
• Advanced Childhood kidney cancers
• Advanced Ewing sarcoma
• Advanced Hodgkin's lymphoma
• Advanced non-Hodgkin's lymphoma
• Aggressive non-Hodgkin's lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/ lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
• Breast cancer
• Childhood rhabdomyosarcoma
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Chronic myelogenous leukemia
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Epithelial ovarian cancer
• Mantle Cell (Non-Hodgkin lymphoma)
• Multiple sclerosis
• Scleroderma
• Scleroderma-SSc (severe, progressive)
• Small cell lung cancer
• Systemic lupus erythematosus
• Systemic sclerosis

30% of our Plan allowance

• National Transplant Program (NTP) - Transplants which are non-experimental or non- investigational are a covered benefit. Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery. The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures. A transplant is non-experimental and non- investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate treatment for your specific condition. Coverage for a transplant where you are the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.

 *Note: Transplants must be performed at hospitals designated as Institutes of Excellence (IOE). Hospitals in our network, but not designated as an IOE hospital will not be covered.

Refer to Note

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four allogenic bone marrow/stem cell transplant donors in addition to the testing of family members.

Refer to Note

Clinical trials must meet the following criteria:

a. The member has a current diagnosis that will most likely cause death within one year or less despite therapy with currently accepted treatment; or the member has a diagnosis of cancer; AND

b. All of the following criteria must be met:

1. Standard therapies have not been effective in treating the member or would not be medically appropriate; and

2. The risks and benefits of the experimental or investigational technology are reasonable compared to those associated with the member's medical condition and standard therapy based on at least two documents of medical and scientific evidence (as defined below); and

3. The experimental or investigational technology shows promise of being effective as demonstrated by the member’s participation in a clinical trial satisfying ALL of the following criteria:

a. The experimental or investigational drug, device, procedure, or treatment is under current review by the FDA and has an Investigational New Drug (IND) number; and

b. The clinical trial has passed review by a panel of independent medical professionals (evidenced by Aetna’s review of the written clinical trial protocols from the requesting institution) approved by Aetna who treat the type of disease involved and has also been approved by an Institutional Review Board (IRB) that will oversee the investigation; and

c. The clinical trial is sponsored by the National Cancer Institute (NCI) or similar national cooperative body (e.g., Department of Defense, VA Affairs) and conforms to the rigorous independent oversight criteria as defined by the NCI for the performance of clinical trials; and

d. The clinical trial is not a single institution or investigator study (NCI designated Cancer Centers are exempt from this requirement); and

4. The member must:

a. Not be treated “off protocol,” and

b. Must actually be enrolled in the trial.

30% of our Plan allowance

Not covered: 

• The experimental intervention itself (except medically necessary Category B investigational devices and promising experimental and investigational interventions for terminal illnesses in certain clinical trials. Terminal illness means a medical prognosis of 6 months or less to live); and
• Costs of data collection and record keeping that would not be required but for the clinical trial; and
• Other services to clinical trial participants necessary solely to satisfy data collection needs of the clinical trial (i.e., "protocol-induced costs"); and
• Items and services provided by the trial sponsor without charge
• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

All charges

Professional services (including Acupuncture - when provided as anesthesia for a covered surgery) provided in:

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

 Note: For sedation or anesthesia relating to dental services performed in a dental office, see Section 5 (g), Dental benefits.

Note: When the anesthesiologist is the primary giver of services, such as for pain management, the specialist cost sharing applies.

30% of our Plan allowance

Room and board, such as

• Private, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

 Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Blood products, derivatives and components, artificial blood products and biological serum. Blood products include any product created from a component of blood such as, but not limited to, plasma, packed red blood cells, platelets, albumin, Factor VIII, Immunoglobulin, and prolastin
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

30% of our Plan allowance

Not covered:

• Whole blood and concentrated red blood cells not replaced by the member
• Non-covered facilities, such as nursing homes, schools
• Custodial care, rest cures, domiciliary or convalescent cares
• Personal comfort items, such as phone and television
• Private nursing care

All charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Radiologic procedures, diagnostic laboratory tests, and X-rays when associated with a medical procedure being done the same day
• Pathology Services
• Administration of blood, blood plasma, and other biologicals
• Blood products, derivatives and components, artificial blood products and biological serum
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.

 Note: Certain devices require precertification by you or your physician. Please see Section 3 for a list of services that require precertification.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non- dental physical impairment. We do not cover the dental procedures.

Note: Preventive care services are not subject to cost sharing listed.

30% of our Plan allowance

Services not associated with a medical procedure being done the same day, such as:

• Mammogram
• Radiologic procedures*
• Lab tests*
• Sleep studies

*See below for exceptions

Note: Preventive care services are not subject to cost sharing listed.

30% of our Plan allowance

Complex diagnostic tests limited to:

• Bone density tests - diagnostic
• CT scans/MRIs/PET scans
• Diagnostic angiography
• Genetic testing - diagnostic*
• Nuclear medicine

 Note: These services need precertification. See Section 3, "Services requiring our prior approval".

* Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient's medical condition.

30% of our Plan allowance

Not covered: Whole blood and concentrated red blood cells not replaced by the member.

All charges

Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 60­ day limit per calendar year when full-time nursing care is necessary and the confinement is medically appropriate as determined by a Plan doctor and approved by the Plan.

30% of our Plan allowance

Not covered: Custodial care

All charges

Supportive and palliative care for a terminally ill member in the home or hospice facility, including inpatient and outpatient care and family counseling, when provided under the direction of a Plan doctor, who certifies the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less.

30% of our Plan allowance

Aetna covers ground ambulance from the place of injury or illness to the closest facility that can provide appropriate care. The following circumstances would be covered:

1. Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or
2. To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or
3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

30% of our Plan allowance

Not covered:

• Ambulance transportation to receive outpatient or inpatient services and back home again, except in an emergency
• Ambulette service
• Ambulance transportation for member convenience or reasons that are not medically necessary

 Note: Elective air ambulance transport, including facility-to-facility transfers, requires prior approval from the Plan.

All charges

• Emergency or urgent care at a doctor’s office

30% of our Plan allowance

• Services provided at a Walk in clinic or CVS MinuteClinic®

$0 per visit

• Emergency or urgent care at an urgent care center

30% of our Plan allowance

• Emergency or urgent care as an outpatient at a hospital (Emergency Room) including doctors' services.

30% of our Plan allowance

Not covered: Elective care or non-emergency care

All charges

• Emergency or urgent care at a doctor’s office

30% of our Plan allowance

• Services provided at a Walk in clinic or CVS MinuteClinic®

$0 per visit

• Emergency or urgent care at an urgent care center

30% of our Plan allowance

• Emergency or urgent care as an outpatient at a hospital (Emergency Room), including doctors' services.

30% of our Plan allowance

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.

All charges

• Teladoc Health® consult

30% of the consult fee

• CVS Health Virtual Care™ consult

$55 per consult until the deductible is met, $0 per consult after deductible has been met

Please see www.aetnafed.com/tools.php for information on medical and behavioral telehealth services.

Members will receive a welcome kit explaining the telehealth benefits.

Aetna covers ground ambulance from the place of injury or illness to the closest facility that can provide appropriate care. The following circumstances would be covered:

1. Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or
2. To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or
3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

Air and sea ambulance may be covered. Prior approval is required.

Note: See 5(c) for non-emergency service.

 30% of our Plan allowance

Not covered:

• Ambulance transportation to receive outpatient or inpatient services and back home again, except in an emergency.
• Ambulette service
• Air ambulance without prior approval
• Ambulance transportation for member convenience or for reasons that are not medically necessary.

 Note: Elective air ambulance transport, including facility-to-facility transfers, requires prior approval from the Plan

All charges

We cover professional services by licensed professional mental health and substance misuse disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Psychiatric office visits to Behavioral Health practitioner
• Substance Use Disorder (SUD) office visits to Behavioral Health practitioner
• Routine psychiatric office visits to Behavioral Health practitioner
• Behavioral therapy

30% of our Plan allowance

Telehealth Behavioral Health consult

30% of our Plan allowance

CVS Health Virtual Care™ telehealth consult

30% of our Plan allowance

• Skilled behavioral health services provided in the home, but only when all of the following criteria are met:
  • Your physician orders them
  • The services take the place of a stay in a hospital or a residential treatment facility, or you are unable to receive the same services outside your home
  • The skilled behavioral health care is appropriate for the active treatment of a condition, illness or disease to avoid placing you at risk for serious complications

30% of our Plan allowance

Applied Behavior Analysis (ABA)

The plan covers medically necessary Applied Behavior Analysis (ABA) therapy when provided by network behavioral health providers. These providers include:

• Providers who are licensed or who possess a state- issued or state-sanctioned certification in ABA therapy.
• Behavior analysts certified by the Behavior Analyst Certification Board (BACB).
• Registered Behavior Technicians (RBTs) certified by the BACB or equivalent paraprofessionals who work under the supervision of a licensed provider or a certified behavior analyst.

 Note: Requires Precertification. See Section 3 “Services requiring our prior approval”.  You are responsible for ensuring that we are asked to precertify your care. You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

30% of our Plan allowance

• Psychological and Neuropsychological testing tests provided and billed by a licensed mental health and SUD treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

30% of our Plan allowance

Inpatient services provided and billed by a hospital or other covered facility including an overnight residential treatment facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

30% of our Plan allowance

Outpatient services provided and billed by a hospital or other covered facility including other outpatient mental health treatment such as:

• Partial hospitalization treatment provided in a facility or program for mental health treatment provided under the direction of a physician
• Intensive outpatient program provided in a facility or program for mental health treatment provided under the direction of a physician
• Outpatient detoxification
• Ambulatory detoxification which is outpatient services that monitor withdrawal from alcohol or other substance abuse, including administration of medications
• Electro-convulsive therapy (ECT)
• Transcranial magnetic stimulation (TMS)
• Psychological/Neuropsychological testing

30% of our Plan allowance

• Educational services for treatment of behavioral disorders
• Services in half-way houses

All charges

We cover the following medications and supplies prescribed by a licensed physician or dentist and obtained from a Plan pharmacy or through our mail order program:

• Drugs approved by the U.S. Food and Drug Administration for which a prescription is required by Federal law, except those listed as Not covered
• Diabetic supplies limited to
  • Lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips
  • Insulin
  • Disposable needles and syringes needed to inject covered prescribed medications
• Prenatal vitamins (as covered under the plan's formulary)
• Drugs to treat gender dysphoria
• Oral and Injectable Infertility medications (includes Artificial Insemination (AI), In vitro fertilization (IVF)/ART medications) 

 Note: If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained.

Note: Certain drugs to treat Gender dysphoria and infertility are considered specialty drugs. Please see Specialty drugs in this section.

Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

$10 per covered preferred generic formulary drug; and

50% per covered preferred brand formulary drug.

Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

$30 per covered preferred generic formulary drug; and

50% per covered preferred brand formulary drug.

Preventive Care Medications

Medications to promote better health as recommended by ACA.

Drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a health care professional and filled at a network pharmacy.

We will cover preventive medications in accordance with the U.S. Preventive Services Task Force (USPSTF) recommendations/guidance:

• Aspirin
• Folic acid supplements
• Oral Fluoride
• Statins
• Breast Cancer Prevention drugs
• HIV PrEP
• Nicotine Replacement Medications (Limits apply)
• Bowel Prep Medications (Required with preventive Colonoscopy)

Please refer to the Aetna formulary guide for a complete list of preventive drugs including coverage details and limitations:
www.aetnafeds.com/pharmacy.php

Note: To receive this benefit a prescription from a doctor must be presented to pharmacy.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy. These may include some over-the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.
uspreventiveservicestaskforce.org/BrowseRec/Index/

Nothing (no deductible)

Women's contraceptive drugs and devices

• Generic oral contraceptives on our formulary list
• Generic emergency contraception, including over-the­ counter (OTC) when filled with a prescription
• Generic injectable contraceptives on our formulary list - five (5) vials per calendar year
• Diaphragms - one (1) per calendar year
• Brand name Intra Uterine Device
• Generic patch contraception

Note: If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at
www.aetnafeds.com/pharmacy.php to review our 2024 Pharmacy Drug (Formulary) Guide or call 800-537-9384.

Nothing (no deductible)

• Brand name contraceptive drugs
• Brand name injectable contraceptive drugs such as Depo Provera - five (5) vials per calendar year
• Brand emergency contraception

Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

50% per covered preferred brand formulary drug.

Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

50% per covered preferred brand formulary drug.

Note: If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained.

Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

$10 per covered preferred generic formulary drug; and

50% per covered preferred brand formulary drug.

Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

$30 per covered preferred generic formulary drug; and

50% per covered preferred brand formulary drug.

Specialty Medications

Specialty medications must be filled through a network specialty pharmacy. These medications are not available through the mail order benefit.

Certain Specialty medications identified on the Specialty Drug List next to the drug name may be covered under the medical or pharmacy section of this brochure. Please refer to above, Specialty Drugs for more information or visit:
www.aetnafeds.com/pharmacy.php

Specialty Pharmacy for up to a 30-day supply per prescription or refill:

$10 per covered preferred generic formulary drug; and

50% per covered preferred brand formulary drug.

Limited benefits:

• Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period. Contact the Plan at 800-537-9384 for dose limits.

Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

$10 per covered preferred generic formulary drug; and

50% per covered preferred brand formulary drug.

Not covered:

• Drugs available without a prescription (i.e., an over-the-counter (OTC) drug) unless required by law.
• Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
• Vitamins, unless otherwise stated (including prescription vitamins), nutritional supplements, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition when administered under the direction of a Plan doctor (please see Durable Medical Equipment in Section 5(a) for more information on what the plan will cover).
• Medical supplies such as dressings and antiseptics
• Lost, stolen or damaged drugs
• Drugs for cosmetic purposes
• Drugs to enhance athletic performance
• Nonprescription medications unless specifically indicated elsewhere
• Prophylactic drugs including, but not limited to, anti­ malarials for travel
• Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
• Compounded thyroid hormone therapy