The Office of Personnel Management (OPM) has determined that Aetna Open Access prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB program.

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

• Visit www.medicare.gov for personalized help.
• Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.

This brochure describes the benefits of our Open Access Plans (High and Standard options) under Aetna* contract (CS 1948) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer Service may be reached at 800-537-9384 or through our website: www.aetnafeds.com. The address for Aetna administrative office is:

Aetna
Federal Plans
PO Box 550
Blue Bell, PA 19422-0550

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits.  You do not have a right to benefits that were available before January 1, 2021, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each Plan annually. Benefit changes are effective January 1, 2021 and changes are summarized on page 17. Rates are shown at the end of this brochure.

* The Aetna companies that offer, underwrite or administer benefits coverage are Aetna Health Inc., Aetna Life Insurance Company, and Aetna Dental Inc.

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples,  

• Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means Aetna.
• We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
• Our brochure and other FEHB Plans’ brochures have the same format and similar descriptions to help you compare plans.

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

• Do not give your Plan identification (ID) number over the phone or to people you do not know, except to your health care providers, authorized health benefits plan or OPM representative.
• Let only the appropriate medical professionals review your medical record or recommend services.
• Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
• Carefully review explanations of benefits (EOBs) statements that you receive from us.
• Periodically review your claims history for accuracy to ensure we have not been billed for services you did not receive.
• Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
• If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
  • Call the provider and ask for an explanation. There may be an error.
  • If the provider does not resolve the matter, call us at 800-537-9384 and explain the situation.
  • If we do not resolve the issue:

CALL- THE HEALTH CARE FRAUD HOTLINE
877-499-7295
OR go to:

www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy and a quicker response time.

You can also write to:

United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100

• Do not maintain as a family member on your policy:
  • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
  • Your child is age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26).

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.

• If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
• Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
• 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 by your provider for services received. 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 is no longer eligible to use your health insurance coverage.

Aetna complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:

Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Attention:  Assistant Director, FEIO, 1900 E Street NW, Suite 3400-S, Washington, DC 20415-3610

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own health care and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

• Ask questions and make sure you understand the answers.
• Choose a doctor with whom you feel comfortable talking.
• Take a relative or friend with you to help you take notes, ask questions, and understand answers.

2. Keep and bring a list of all the medications you take.

• Bring the actual medications or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
• Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
• Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
• Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected.
• Read the label and patient package insert when you get your medication, including all warnings and instructions
• Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
• Contact your doctor or pharmacist if you have any questions.
• Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic..

3. Get the results of any test or procedure.

• Ask when and how you will get the results of test or procedures. Will it be in person, by phone, mail, through the Plan or Provider's portal?
• Don't assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results be it in person, by phone, or by mail.
• Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinics best for your health needs.

• Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the health care you need.
• Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

• Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
• Ask your doctor, "Who will manage my care when I am in the hospital"
• Ask your surgeon:
  • "Exactly what will you be doing?"
  • "About how long will it take?"
  • "What will happen after surgery?"
  • "How can I expect to feel during recovery?"
• Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit

• www.jointcommission.org/speakup.aspx. The Joint Commission's Speak Up™ patient safety program.
• www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps health care organizations to improve the quality and safety of the care they deliver.
• www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.
• www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
• www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
• www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a health care facility. These conditions and errors are sometimes called "Never Events" or "Serious Reportable Events."

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error.

Coverage information

When you lose benefits

This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory or visit our website at www.aetnafeds.com. We give you a choice of enrollment in a High Option or a Standard Option.

OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Aetna holds the following accreditations: National Committee for Quality Assurance and/or the local plans and vendors that support Aetna hold accreditation from the National Committee for Quality Assurance. To learn more about this plan’s accreditation(s), please visit the following website:

• National Committee for Quality Assurance (www.ncqa.org)

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the Plan’s benefits, not because a particular provider is available. You cannot change Plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

General features of both our High and Standard Options

Features of our High Option

• A calendar year deductible of $1,000 Self Only and $3,000 for Self Plus One or Self and Family. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
• The catastrophic protection per calendar year is $6,000 for Self Only and $10,000 for Self Plus One or Self and Family. 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 or Self and Family out-of-pocket maximum can be satisfied by one or more family members.

Features of our Standard Option

• A calendar year deductible of $2,000 Self Only and $6,000 for Self Plus One or Self and Family. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
• The catastrophic protection per calendar year is $6,000 for Self Only and $10,000 for Self Plus One or Self and Family. 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 or Self and Family out-of-pocket maximum can be satisfied by one or more family members.

We have Open Access Benefits

Our HMO offers Open Access benefits. This means you can receive covered services from a participating network specialist without a required referral from your primary care physician or by another participating provider in the network.

This Open Access Plan is available to members in our FEHBP service area. If you live or work in an Open Access HMO service area, you can go directly to any network specialist for covered services without a referral from your primary care physician. Note: Whether your covered services are provided by your selected primary care physician (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 at 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.

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).

This is a direct contract prepayment Plan, which means that participating providers are neither agents nor employees of the Plan; rather, they are independent doctors and providers who practice in their own offices or facilities. The Plan arranges with licensed providers and hospitals to provide medical services for both the prevention of disease and the treatment of illness and injury for benefits covered under the Plan.

Specialists, hospitals, primary care physicians and other providers in the Aetna network have agreed to be compensated in various ways:

• Per individual service (fee-for-service at contracted rates),
• Per hospital day (per diem contracted rates),
• Under capitation methods (a certain amount per member, per month), and
• By Integrated Delivery Systems ("IDS"), Independent Practice Associations ("IPAs"), Physician Medical Groups ("PMGs"), Physician Hospital Organizations ("PHOs"), behavioral health organizations and similar provider organizations or groups that are paid by Aetna; the organization or group pays the physician or facility directly. In such arrangements, that group or organization has a financial incentive to control the costs of providing care.

One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal. You are encouraged to ask your physicians and other providers how they are compensated for their services.

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www.opm.gov/healthcare-insurance) lists the specific types of information that we must make available to you. Some of the required information is listed below.

• Aetna has been in existence since 1850
• Aetna is a for-profit organization

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, www.aetnafeds.com. You can also contact us to request that we mail a copy to you.

If you want more information about us, call 800-537-9384 or write to Aetna at P.O. Box 550, Blue Bell, PA 19422-0550. You may also visit our website at www.aetnafeds.com.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.aetnafeds.com to obtain our Notice of Privacy Practices.  You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Medical Necessity

"Medical necessity" means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is:

• In accordance with generally accepted standards of medical practice; and,
• Clinically appropriate in accordance with generally accepted standards of medical practice in terms of type, frequency, extent, site and duration, and considered effective for the illness, injury or disease; and,
• Not primarily for the convenience of you, or for the physician or other health care provider; and,
• Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the illness, injury or disease.

For these purposes, "generally accepted standards of medical practice," means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors.

Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial letters for such decisions delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal process.

Direct Access Ob/Gyn Program

This program allows female members to visit any participating gynecologist for a routine well-woman exam, including a Pap smear, one visit per calendar year. The program also allows female members to visit any participating gynecologist for gynecologic problems. Gynecologists may also refer a woman directly to other participating providers for specialized covered gynecologic services. All health plan preauthorization and coordination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG), an Integrated Delivery System (IDS) or a similar organization, your care must be coordinated through the IPA, the PMG, the IDS, or similar organization and the organization may have different referral policies.

Mental Health/Substance Misuse

Behavioral health services (e.g., treatment or care for mental disease or illness, alcohol abuse and/or substance misuse) are managed by Aetna Behavioral Health. We also make initial coverage determinations and coordinate referrals, if required; any behavioral health care referrals will generally be made to providers affiliated with the organization, unless your needs for covered services extend beyond the capability of these providers. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the terms of your health plan.

Ongoing Reviews

We conduct ongoing reviews of those services and supplies which are recommended or provided by health professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such determination, you may then contact us to seek a review of the determination.

Authorization

Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits under this Plan. See section 3, "You need prior plan approval for certain services."

Patient Management

We have developed a patient management program to assist in determining what health care services are covered and payable under the health plan and the extent of such coverage and payment. The program assists members in receiving appropriate health care and maximizing coverage for those health care services.

Where such use is appropriate, our utilization review/patient management staff uses nationally recognized guidelines and resources, such as Milliman Care Guidelines^© and InterQual^® ISD criteria, to guide the precertification, concurrent review and retrospective review processes. To the extent certain utilization review/patient management functions are delegated to integrated delivery systems, independent practice associations or other provider groups ("Delegates"), such Delegates utilize criteria that they deem appropriate.

• 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. Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services. When you are to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment.

• Concurrent Review: The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require Concurrent Review.
• Discharge Planning: Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by you upon discharge from an inpatient stay.
• Retrospective Record Review: The purpose of retrospective record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions for coverage and payment of health care services. Our effort to manage the services provided to you includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and utilization concerns.

Member Services

Representatives from Member Services are trained to answer your questions and to assist you in using the Aetna Plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free number on the card when you need to:

• Ask questions about benefits and coverage.
• Notify us of changes in your name, address or phone number.
• Change your primary care physician or office.
• Obtain information about how to file a grievance or an appeal

Privacy Notice

How we guard your privacy - We’re committed to keeping your personal information safe 

What personal information is — and what it isn’t -  By “personal information,” we mean that which can identify you. It can include financial and health information. It doesn’t include what the public can easily see. For example, anyone can look at what your plan covers. 

How we get information about you -  We get information about you from many sources, including from you. But we also get information from your employer, other insurers, or health care providers like doctors. 

When information is wrong -  Do you think there’s something wrong or missing in your personal information? You can ask us to change it. The law says we must do this in a timely way. If we disagree with your change, you can file an appeal. Information on how to file an appeal is on our member website. Or you can call the toll-free number on your ID card. 

How we use this information -  When the law allows us, we use your personal information both inside and outside our company. The law says we don’t need to get your permission when we do.

We may use it for your health care or use it to run our plans. We also may use your information when we pay claims or work with other insurers to pay claims. We may use it to make plan decisions, to do audits, or to study the quality of our work.

This means we may share your info with doctors, dentists, pharmacies, hospitals or other caregivers. We also may share it with other insurers, vendors, government offices, or third-party administrators. But by law, all these parties must keep your information private. 

When we need your permission -  There are times when we do need your permission to disclose personal information.

This is explained in our Notice of Privacy Practices, which took effect October 9, 2018. This notice clarifies how we use or disclose your Protected Health Information (PHI):

• For workers’ compensation purposes
• As required by law
• About people who have died
• For organ donation
• To fulfill our obligations for individual access and HIPAA compliance and enforcement 

To get a copy of this notice, just visit our member website. Or call the toll-free number on your ID card.

If you want more information about us, call 800-537-9384, or write to Aetna, Federal Plans, PO Box 550, Blue Bell, PA 19422-0550. You may also contact us by fax at 860-975-1669 or visit our website at www.aetnafeds.com.

Service Area

To enroll in this Plan, you must live in or work in our service area. This is where our providers practice.

Our Kansas City Metropolitan service area is:

Kansas – Anderson, Allen, Atchison, Bourbon, Brown, Cherokee, Crawford, Doniphan, Douglas, Franklin, Jackson, Jefferson, Johnson, Labette, Leavenworth, Linn, Marshall, Miami, Montgomery, Neosho, Osage, Pottawatomie, Shawnee, Wabaunsee, and Wyandotte Counties

Missouri – Andrew, Barton, Benton, Buchanan, Caldwell, Carroll, Cass, Christian, Clay, Clinton, Dade, Dallas, Daviess, DeKalb, Gentry, Greene, Grundy, Henry, Jackson, Jasper, Johnson, Lafayette, Lawrence, Livingston, Newton, Pettis, Polk, Platte, Ray, Vernon and Webster Counties

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior Plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), they will be able to access full HMO benefits if they reside in any Aetna HMO service area by selecting a PCP in that service area. If not, you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

Changes to High Option only

• Enrollment Code HA. Your share of the non-Postal premium will increase for Self Only, increase for Self Plus One, and increase for Self and Family. (See page 106)

Changes to Standard Option only

• Enrollment Code HA. Your share of the non-Postal premium will increase for Self Only, increase for Self Plus One, and increase for Self and Family. (See page 106)

Changes to the Plan (All Options)

• Services that require plan approval (other services) – The Plan updated its list of services that require plan approval. Services that now must be preauthorized are: Functional endoscopic sinus surgery, Arthrodesis for spine deformity and Kyphectomy. (See page 20)
• Treatment therapies - The Plan is changing from 25% of the Plan allowance after the deductible to $60 per visit, no deductible. (See page 37) 
• Intravenous (IV) infusion therapy and medication – The Plan is changing from 25% of the Plan allowance after the deductible to $60 per visit, no deductible. (See page 43)
• Specialty drugs - The Plan will now require members to fill all specialty drugs at an Aetna Performance Specialty Network pharmacy. (See page 70) 
• True accumulation for specialty drugs - The Plan will now apply true accumulation. Some specialty medications may qualify for third-party copayment assistance programs that could lower your out of-pocket costs for those products. For any such specialty medication where third-party copayment assistance is used, the member shall not receive credit toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate.  (See page 72)
• Voluntary maintenance choice - Through voluntary maintenance choice, members can fill maintenance drugs (30-90 day supply) either through home delivery or at CVS/pharmacy retail locations. (See page 72) 

This is what you will pay out-of-pocket for covered care:

See page 17 for how our benefits changed this year. On page 104 and page 105 is a benefit summary of each option. Make sure that you review the benefits that are available under the option which you are enrolled.

This Plan offers both a High and Standard Option. Both benefit packages are described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

The High and Standard Option Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about High and Standard Option benefits, contact us at 800-537-9384 or on our website at www.aetnafeds.com.

Each option offers unique features.

• You are not required to select a primary care physician. Please be sure the provider you select – or the provider or facility you are referred to – is part of the Aetna Open Access HMO Network. It is ultimately your responsibility to verify this information. By doing so, you get the most from your health Plan and protect yourself from paying more than you have to for covered benefits.
• You do not need a referral from a primary care physician to see a specialist.
• These Plans include annual wellness/preventive care exams to You at no cost.
• Routine eye exams are available to all members.
• These Plans include preventive dental diagnostic services using the Aetna PPO Dental Network.
• You can use Aetna Health Connections Disease Management Programs which are available for thirty-four conditions.

Features of our High Option

• A calendar year deductible of $1,000 Self Only and $3,000 for Self Plus One or Self and Family. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
• Catastrophic protection per calendar year is $6,000 for Self Only and $10,000 for Self Plus One or Self and Family. 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 or Self and Family out-of-pocket maximum can be satisfied by one or more family members.

Features of our Standard Option

• A calendar year deductible of $2,000 Self Only and $6,000 for Self Plus One or Self and Family. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
• Catastrophic protection per calendar year is $6,000 for Self Only and $10,000 for Self Plus One or Self and Family. 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 or Self and Family out-of-pocket maximum can be satisfied by one or more family members. 

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Plan physicians must provide or arrange your care.
• A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
• High Option: The calendar year deductible is $1,000 Self Only, $3,000 Self Plus One and $3,000 Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added ("No Deductible") to show when the calendar year deductible does not apply.
• Standard Option: The calendar year deductible is $2,000 Self Only, $6,000 Self Plus One and $6,000 Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added ("No Deductible") to show when the calendar year deductible does not apply.

• Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
• If you live or work in an Aetna Open Access HMO service area, you do not have to obtain a referral from your PCP to see a network specialist.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Plan physicians must provide or arrange your care.
• The calendar year deductible is: High Option: $1,000 Self Only, $3,000 Self Plus One and $3,000 Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.
• The calendar year deductible is: Standard Option: $2,000 Self Only, $6,000 Self Plus One and $6,000 Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.

• Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).
• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
• High Option: The calendar year deductible is $1,000 Self Only, $3,000 Self Plus One and $3,000 Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added ("No Deductible") to show when the calendar year deductible does not apply.
• Standard Option: The calendar year deductible is $2,000 Self Only, $6,000 Self Plus One and $6,000 Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added ("No Deductible") to show when the calendar year deductible does not apply.

• Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

• Be sure to read Section 4, Your costs for covered services for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
• The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

• We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization.  After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply. 

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• High Option: The calendar year deductible is $1,000 Self Only, $3,000 Self Plus One and $3,000 for Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added ("No Deductible") to show when the calendar year deductible does not apply.
• Standard Option: The calendar year deductible is $2,000 Self Only, $6,000 Self Plus One and $6,000 for Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added ("No Deductible") to show when the calendar year deductible does not apply.

• Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about Coordinating benefits with other coverage, including with Medicare.
• We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization.  After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply. 

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

Emergencies within our service area:

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person’s health, or with respect to a pregnant woman, the health of the woman and her unborn child.

Whether you are in or out of an Aetna HMO service area, we simply ask that you follow the guidelines below when you believe you need emergency care.

• Call the local emergency hotline (e.g., 911) or go to the nearest emergency facility. For non-emergency services, care may be obtained from a retail clinic, a walk-in clinic, an urgent care center or by calling Teladoc. If a delay would not be detrimental to your health, call your primary care physician. Notify your primary care physician as soon as possible after receiving treatment.
• After assessing and stabilizing your condition, the emergency facility should contact your primary care physician so he/she can assist the treating physician by supplying information about your medical history.
• If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Aetna as soon as possible.

Emergencies outside our service area:

If you are traveling outside your Aetna service area or if you are a student who is away at school, you are covered for emergency and urgently needed care. For non-emergency services, care may be obtained from a walk-in clinic, an urgent care center or by calling Teladoc. Urgent care may be obtained from a private practice physician, a walk-in clinic or an urgent care center. Certain conditions, such as severe vomiting, earaches, sore throats or fever are considered “urgent care” outside your Aetna service area and are covered in any of the above settings.

If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or emergency problem does not qualify for coverage, it may be necessary to provide us with additional information. We will send you an Emergency Room Notification Report to complete, or a Member Services representative can take this information by phone.

Follow-up Care after Emergencies

All follow-up care should be coordinated by your PCP or network specialist. Follow-up care with non-participating providers is only covered with a referral from your primary care physician and pre-approval from Aetna. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care.

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• High Option: The calendar year deductible is $1,000 Self Only, $3,000 Self Plus One and $3,000 Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added ("No Deductible") to show when the calendar year deductible does not apply.
• Standard Option: The calendar year deductible is $2,000 Self Only, $6,000 Self Plus One and $6,000 Self and Family. The calendar year deductible applies to almost all benefits in this Section. We added ("No Deductible") to show when the calendar year deductible does not apply.
• Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
• YOU MUST GET PREAUTHORIZATION FOR CERTAIN SERVICES. Aetna can assist you in locating participating providers in the Plan, unless your needs for covered services extend beyond the capability of the affiliated providers. Emergency care is covered (See Section 5(d), Emergency services/accidents). You can receive information regarding the appropriate way to access the behavioral health care services that are covered under your specific plan by calling Member Services at 800-537-9384. A referral from your PCP is not necessary to access behavioral health care but your PCP may assist in coordinating your care. Please see Section 3 of this brochure for a list of services that require preauthorization.
• We will provide medical review criteria or reasons for treatment plan denials to enrollees, patient or providers upon request or as otherwise required.
• OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

Important things you should keep in mind about these benefits:

• This is a five tier open formulary pharmacy plan, Advanced Control Formulary. The formulary is a list of drugs that your health plan covers. With your Advanced Control Formulary Pharmacy plan, each drug is grouped as generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Each tier has a separate out of pocket cost.
  • Preferred generic
  • Preferred brand
  • Non-Preferred generic and brand
  • Preferred specialty
  • Non-preferred specialty
• We have no calendar year deductible for Prescription drugs.
• We cover prescribed drugs and medications, as described in the chart beginning on the next page.
• Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Members must make sure their prescribers obtain prior approval/authorization for certain prescription drugs and supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
• Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. Upon approval by the Plan, the prescription is covered for the current calendar year or a specified time period, whichever is less.
• Federal law prevents the pharmacy from accepting unused medications.

There are important features you should be aware of. These include:

• Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/or certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
• Where you can obtain them. You may fill non-emergency prescriptions at a participating Plan retail pharmacy or by mail order for up to a 90-day supply of medication (if authorized by your physician). You may obtain up to a 30-day supply of medication for one (1) copay, and for a 31-day up to a 90-day supply of medication for three (3) copays. In no event will the copay exceed the cost of the prescription drug. Please call Member Services at 800-537-9384 for more details on how to use the mail order program. Mail order is not available for drugs and medications ordered through a network specialty pharmacy. Prescriptions ordered through a network specialty pharmacy are only filled for up to a 30-day supply due to the nature of these prescriptions. In an emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. For retail pharmacy transactions, you must present your Aetna Member ID card at the point of sale for coverage. If you obtain an emergency prescription at a pharmacy that does not participate with the plan, you will need to pay the pharmacy the full price of the prescription and submit a claim for reimbursement subject to the terms and conditions of the plan.
• We use a formulary.  The formulary is a list of drugs that your Plan covers. Drugs are prescribed by Plan doctors and dispensed in accordance with the 2021 Pharmacy (Formulary) Drug Guide. Certain drugs require your doctor to get precertification or step therapy from the Plan before they can be covered under the Plan. Your prescription drug plan includes drugs listed in the 2021 Pharmacy (Formulary) Drug Guide. Prescription drugs listed on the formulary exclusions list are excluded unless a medical exception is approved by the Plan. 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 to review 2021 Pharmacy (Formulary) Drug Guide or call 800-537-9384.
• Drugs not on the formulary. Formularies are developed and reviewed by the CVS Caremark Pharmacy and Therapeutics Committee, comprised of physicians, pharmacists and other clinicians that review drugs for inclusion in the formulary. They consider the drug's effectiveness and safety in their evaluation. While most of the drugs on the non-formulary list are brand drugs, some generic drugs also may be on the non-formulary list. For example, this may happen when brand medications lose their patent and the FDA has granted a period of exclusivity to specific generic manufacturers. When this occurs, the price of the generic drug may not decrease as you might think most generic drugs do. This period of exclusivity usually ranges between 3-6 months. Once this time period expires, competition from other generic manufacturers will generally occur and this helps lower the price of the drug and this may lead the Plan to re-evaluate the generic for possible inclusion on the formulary. We will place some of these generic drugs that are granted a period of exclusivity on our non-formulary list, which requires the highest copay level. Remember, a generic equivalent will be dispensed, if available, unless your physician specifically requires a brand name and writes "Dispense as Written" (DAW) on the prescription, so discuss this with your doctor.
• Choose generics. The Plan requires the use of generics if a generic drug is available. 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 from the Plan. Generics contain the same active ingredients in the same amounts as their brand name counterparts and have been approved by the FDA. By using generic drugs, you will see cost savings, without jeopardizing clinical outcome or compromising quality. *The differential/penalty will not apply to Plan accumulators. (example: deductible and out-of-pocket maximum)
• Precertification. Your pharmacy benefits plan includes precertification. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-approved by our Pharmacy Management Precertification Unit before they will be covered. Only your physician or pharmacist, in the case of an antibiotic or analgesic, can request precertification for a drug. Step-therapy is another type of precertification.  Certain medications will be excluded from coverage unless you try one or more "step" drug(s) first, or unless a medical exception is obtained. The drugs requiring precertification or step-therapy are subject to change. Visit our website at www.aetnafeds.com/pharmacy for the most current information regarding the precertification and step-therapy lists. Ask your physician if the drugs being prescribed for you require precertification or step-therapy.
• These are the dispensing limitations. Prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy or by mail order may be dispensed for up to a 90-day supply of medication (if authorized by your physician). You may obtain up to a 30-day supply of medication for one copay, and a 31-day up to a 90-day supply of medication for three copays. In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name.
  
  In the event that a member is called to active military duty and requires coverage under their prescription plan benefits of an additional filing of their medication(s) prior to departure, their pharmacist will need to contact us. Coverage of additional prescriptions will only be allowed if there are refills remaining on the member's current prescription or a new prescription has been issued by their physician. The member is responsible for the applicable copayment for the additional prescription.
• The Plan allows coverage of a medication refill when at least 80% of the previous prescription, according to the physician's prescribed directions, has been utilized. For a 30-day supply of medication, this provision would allow a prescription refill to be covered 24 days after the last filling, thereby allowing a member to have an additional supply of their medication, in case of emergency.
• When you do have to file a claim. Send your itemized bill(s) to: Aetna, Pharmacy Management, P.O. Box 52444, Phoenix, AZ 85072-2444.

Here are some things to keep in mind about our prescription drug program:

• A generic equivalent may be dispensed if it is available, and where allowed by law.

• Mail order pharmacy. Generally, the drugs available through mail order are maintenance drugs that you take on a regular basis for a chronic or long-term medical condition. Outpatient prescription drugs are covered when dispensed by a network mail order pharmacy or a CVS pharmacy®. Each prescription is limited to a maximum 90-day supply. Prescriptions for less than a 30-day supply or more than a 90-day supply are not eligible for coverage when dispensed by a network mail order pharmacy.

• Specialty drugs. Specialty drugs are medications that treat complex, chronic diseases which includes select oral, injectable and infused medications. The first fill including all subsequent refills of these medications must be obtained through a network specialty pharmacy.
  
  Certain Specialty Formulary medications identified on the Specialty Drug list may be covered under the medical or pharmacy section of this brochure depending on how and where the medication is administered. If the provider supplies and administers the medication during an office visit, you will pay the applicable PCP or specialist office visit copay. If you obtain the prescribed medications directly from a network specialty pharmacy.  You will pay the applicable copay as outlined in Section 5(f) of this brochure.
  
  Often these drugs require special handling, storage and shipping. For a detailed listing of specialty medications visit www.aetnafeds.com/pharmacy or contact us at 800-537-9384 for a copy. Note that the medications and categories covered are subject to change. Some specialty medications may qualify for third-party copayment assistance programs that could lower your out of-pocket costs for those products. For any such specialty medication where third-party copayment assistance is used, you shall not receive credit toward your out-of-pocket maximum or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate.  

• To request a printed copy of the 2021 Pharmacy Drug (Formulary) Guide, call 800-537-9384. The information in the 2021 Pharmacy Drug (Formulary) Guide is subject to change. As brand name drugs lose their patents and new generics become available on the market, the brand name drug may be removed from the formulary. Under your benefit plan, this will result in a savings to you, as you pay a lower prescription copayment for generic formulary drugs. Please visit www.aetnafeds.com/pharmacy for current 2021 Pharmacy Drug (Formulary) Guide information.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
• We have no calendar year deductible for diagnostic and preventive services.

Note: You will be covered automatically under the Dental PPO option.

• Under the Dental PPO option, the Plan covers 100% of the charges for those preventive and diagnostic procedures shown on the next page when using a participating network dentist. Participating network PPO dentists may offer members other services at discounted fees.  Discounts may not be available in all states. Providers are not required to honor the contracted rate/discount for dental services that are not covered or not listed in this section. 
• We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described on the next pages.
• Some procedures and treatments may have specific age and frequency limitations as noted below.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

Dental PPO

Under this option, you have to use our participating Dental PPO network dentists. 

Dental PPO In-Network Option

The plan covers 100% of the charges for those preventive and diagnostic shown on the previous page when using a participating network dentist. Participating network PPO dentists may offer members other services at discounted fees.  Discounts may not be available in all states. Please call Member Services at 800-537-9384 for specific fees for your procedure.

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information, contact the plan at 888-238-6240 or visit their website at www.aetnafeds.com.

Vision Discounts

At Aetna, you get discounts on eyeglass frames from budget to designer brands, non-disposable contact lenses, the latest in lens technology, sunglasses, and more. With these built in discounts you’ll also see savings on LASIK laser eye surgery and popular lens options. You can visit many doctors in private practice. Plus, national chains like LensCrafters^®, Target Optical^®, and Pearle Vision^®. You can find them all on your member website at aetnafeds.com.

Hearing Discounts

The hearing discounts can help you and your covered family members save on hearing exams, a large choice of leading brand hearing aids, batteries and free routine follow-up services. There are two ways for you to save at thousands of locations through Hearing Care Solutions or Amplifon Hearing Health Care. Visit your member website at aetnafeds.com for more information once you are a member.  

Healthy lifestyle discounts

Save on gym memberships, health coaching, fitness gear and nutrition products that support a healthy lifestyle. You get access to local and national discounts on brands you know. At-home weight-loss programs with tips and menus; track progress from the privacy of your home. You can also save on wearable fitness devices, meditation, yoga, wellness programs and oral health care products.  (Through our partnership with LifeMart^®, you can also save on thousands of products and services, including health and wellness products, tickets, car rentals and coupons).

Natural products and services discount

Save on natural products and services. Enjoy these services* at a discount off the normal fee.  Ease your stress and tension with therapeutic massage. Heal pain or stress points with acupuncture or chiropractic care.** Get advice from registered dietitians with nutrition services. Visit your member website at aetnafeds.com for more information once you are a member.

* The ChooseHealthy^® program is provided by ChooseHealthy, Inc., a subsidiary of American Specialty Health Incorporated (ASH). ChooseHealthy is a federally registered trademark of ASH and used with permission here in.

**Discounts do not apply to visits/claims submitted to your health insurance plan.

Once you’re a member, for full details on these discount programs and more, log in to your member website at aetnafeds.com and select the “Stay Healthy” tab.

Discount offers may be available but are not guaranteed under our contract with the FEHB program. Please see aetnafeds.com for details.

Discount offers are not offers of insurance. They are not benefits under your health plan. You receive access to discounts off the regular charge on products and services offered by third-party vendors and providers. Aetna makes no payment to the third parties; you are responsible for the full cost.  Check any health plan benefits you have before using these discount offers, as those benefits may give you lower costs than these discounts. Vendors and providers are not agents of Aetna and are solely responsible for the products and services they provide. Discount offers are not guaranteed and may be ended at any time. Aetna may get a fee when you buy these discounted products and services. Vision care providers are contracted through EyeMed Vision Care. LASIK surgery discounts are offered by the U.S. Laser Network and QualSight. Hearing products and services are provided by Hearing Care Solutions and Amplifon Hearing Health Care.

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure.  Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 When you need prior Plan approval for certain services. 

We do not cover the following:

• Care by non-Plan providers except for authorized referrals or emergencies (see Emergency services/accidents).
• Services, drugs, or supplies you receive while you are not enrolled in this Plan.
• Services, drugs, or supplies not medically necessary or not within the Plan's utilization policies and procedures.
• Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
• Educational classes, programs, and other rehabilitative therapies not otherwise listed as covered.
• Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants).
• Procedures, services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest .
• Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
• Services, drugs, or supplies you receive without charge while in active military service.
• Cost of data collection and record keeping for clinical trials that would not be required, but for the clinical trial.
• Items and services provided by clinical trial sponsor without charge.
• Care for conditions that state or local law requires to be treated in a public facility, including but not limited to, mental illness commitments.
• Court ordered services, or those required by court order as a condition of parole or probation, except when medically necessary.
• Services provided by a family member or resident in the member’s home.
• Services or supplies we are prohibited from covering under the Federal law.

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider.

If you need to file the claim, here is the process:

You may appeal to the U.S. Office of Personnel Management (OPM) if we do not follow the required claims process.  For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Section 3, 7, and 8 of this brochure, please call Aetna's Customer Service at the phone number found on your ID card, plan brochure or plan website: www.aetnafeds.com.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions. 

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.  To make your request, please contact our Customer Service Department by writing Aetna, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512 or calling 800-537-9384. 

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or his/her subordinate, who made the initial decision.

When our initial decision is based (in whole or in part) on a medical judgement (i.e., medically necessity, experimental/investigational), we will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgement and who was not involved in making the initial decision.

Our reconsideration decision will not afford deference to the initial decision and will be conducted by a plan representative who is neither the individual who made the initial decision that is the subject of the reconsideration, nor the subordinate of that individual.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-537-9384.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues.  For example, we do not determine whether you or a dependent are covered under this plan.  You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.

• Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions , limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.aetnafeds.com.
• If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
• We only cover services provided or arranged by Plan physicians, except in emergencies.

• Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.aetnafeds.com.
• If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
• We only cover services provided or arranged by Plan physicians, except in emergencies.

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

Postal rates apply to certain United States Postal Service employees as follows:

• Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreement: NALC.
• Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement: PPOA.

Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career bargaining unit employees who are represented by the following agreements: APWU, IT/AS, NPMHU, NPPN and NRLCA. Postal rates do not apply to non-career Postal employees, Postal retirees, and associate members of any Postal employee organization who are not career Postal employees.

If you are a Postal Service employee and have questions or require assistance, please contact:

USPS Human Resources Shared Service Center: 1-877-477-3273, option 5, Federal Relay Service 1-800-877-8339

Premiums for Tribal employees are shown under the monthly non-Postal column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.