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 member. 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 carrier to add a family member when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a family member if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches 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 by 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 below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described 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 processed according to the 2023 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 2022 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 benefits under the Plan during the continuance of the confinement but not beyond the 60th 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 divorced from a Federal employee or annuitant, you may not continue to get benefits 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: www.opm.gov/healthcare-insurance/healthcare/plan-information/.  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 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 job, or if you are a covered child and you turn age 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 apply in writing to us 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 apply in writing to us 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.

This Open Access Plan is available to our members in those FEHBP service areas identified starting in Section 1. You can go directly to any network specialist for covered services without a referral from your primary care physician. 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 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 (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 medical 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.

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The most current information on our Plan providers is also on our website at www.aetnafeds.com under our online provider directory.

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.

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

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

Your primary care physician 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 physician 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 physician. 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 physician, 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.

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 Customer Service 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 physician 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.

Your primary care physician 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 (Iatrogenic infertility) 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:
  • Carpal tunnel surgery
  • Complex wound repair
  • Cystourethroscopy
  • Hemorrhoidectomy
  • Hernia repair
  • Hysteroscopy
  • Intranasal dermatoplasty
  • Lithotripsy
  • Prostate biopsy
  • Septoplasty
  • Skin tissue transfer or rearrangement
  • Subcutaneous soft tissue excision
  • Tonsillectomy (age 12 or older)
• Spinal procedures, such as:
  • Artificial intervertebral disk 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
• 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®, Outpatient physical therapy (PT) and occupational therapy (OT) precertification, 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 service 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 of 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 of 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 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 an 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 judgement of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim 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 of (1) 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 claims 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 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 a vaginal delivery or a total of five (5) days or less for a cesarean, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then 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.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claim 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.

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

Example: In our Plan, you pay 50% of our allowance for covered durable medical equipment.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. You are responsible for paying copayments to providers at the time of service.

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. 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.

High Option Plan:

The calendar year deductible is $1,000 Self Only, $3,000 Self Plus One and $3,000 Self and Family.

Standard Option Plan:

The calendar year deductible is $2,000 Self Only, $6,000 Self Plus One and $6,000 Self and Family. 

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.

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, any applicable deductible, and coinsurance total the amounts listed below, you do not have to pay any more for covered services.  The Self Plus One or Self and Family out-of-pocket maximum must be satisfied by one or more family members before the plan will begin to cover eligible medical expenses at 100%.  Be sure to keep accurate records and receipts of your copayments, applicable deductible and coinsurance to ensure the Plan's calculation of your out-of-pocket maximum is reflected accurately.

High Option Plan: After your copayments, deductible, and coinsurance total the amounts listed below in the calendar year, you do not have to pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments or coinsurance for: Dental benefits and infertility services.

Under our High Option Plan the out-of-pocket maximum is $6,000 for Self Only, $10,000 for Self Plus One and $10,000 for 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.

Standard Option Plan: After your copayments, deductible, and coinsurance total the amounts listed below in the calendar year, you do not have to pay any more for covered services. However, copayments, deductible, or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments or coinsurance for: Dental benefits and infertility services.

Under our Standard Option Plan the out-of-pocket maximum is $6,000 for Self Only, $10,000 for Self Plus One and $10,000 for 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.

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” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

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 unexpected bills.

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, not including minor surgery

$30 per visit to a primary care physician or OB/GYN, No Deductible

$30 per visit to a primary care physician or OB/GYN, No Deductible

$60 per visit to a specialist, No Deductible

Professional services of physicians

• In an urgent care center

Nothing

Nothing

• During a hospital stay
• In a skilled nursing facility

25% of our allowance

30% of our allowance

• Office medical evaluations, examinations and consultations
• Second Surgical opinion
• At home

$30 per visit to a primary care physician or OB/GYN, No Deductible

$60 per visit to a specialist, No Deductible

$30 per visit to a primary care physician or OB/GYN, No Deductible 

$60 per visit to a specialist, No Deductible 

• Teladoc

Please see www.aetnafeds.com for additional details and updates on Teladoc service.

Note: Members will receive a Teladoc welcome kit explaining the benefit

Note: For Behavioral Health telemedicine consults, please see section 5(e).

$40 per consult (no deductible) 

$40 per consult (no deductible) 

Tests, such as:

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

25% of our allowance

30% of our allowance

• X-ray

25% of our allowance

30% of our allowance

Hi Tech Diagnostics

• MRI
• MRA
• CT and PET Scans
• Cardiac Catheterization
• Thallium 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.

25% of our allowance

30% of our allowance

• 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/DTaP, 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://www.uspreventiveservicestaskforce.org
• 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

Nothing, No Deductible

Routine mammogram - covered

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

• One (1) routine eye exam every 12 months
• One (1) routine hearing exam every 24 months

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.

Not covered:

• Physical exams and immunizations 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 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, 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://www.uspreventiveservicestaskforce.org
• 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 age 12 months
  • Three (3) routine exams from age 12 months to 24 months
  • Three (3) routine exams 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 recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing, No Deductible

Nothing, No Deductible

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.

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

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

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).
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).
• Screening for gestational diabetes
• Delivery
• Postnatal care

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.

$30 for initial office visit to confirm pregnancy, No Deductible

All other copayments for routine prenatal visits during the course of pregnancy are waived. See Section 5(c) for Maternity Care received at an Inpatient Hospital.

$30 for initial office visit to confirm pregnancy, No Deductible 

All other copayments for routine prenatal visits during the course of pregnancy are waived. See Section 5(c) for Maternity Care received at an Inpatient Hospital.

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.

Note: We cover oral contraceptives under the prescription drug benefit.

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

$30 per visit to a primary care physician, No Deductible
$60 per visit to a specialist, No Deductible

$30 per visit to a primary care physician, No Deductible
$60 per visit to a specialist, No Deductible

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Infertility is a disease defined by the failure to conceive a pregnancy after 12 months or more of timed intercourse or egg-sperm contact for women under age 35 (six (6) months for women age 35 or older).

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.* **

* 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.

Not covered:

• Any assisted reproductive technology (ART) procedure or services related to such procedures, including but not limited to in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and intra-cytoplasmic sperm injection (ICSI)
• Artificial insemination (AI) and monitoring of ovulation:
  - Intravaginal insemination (IVI)
  - Intracervical insemination (ICI)
  - Intrauterine insemination (IUI) 
• Ovulation induction cycle(s) while on injectable medication to stimulate the ovaries
• Any charges associated with care required to obtain Artificial insemination or ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc.); and any charges associated with obtaining sperm for any Artificial insemination or 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
• Injectable fertility drugs including but not limited to menotropins, hCG, GnRH agonists, and IVIG
• Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services
• 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

• Testing and treatment

30% of our allowance

• 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

$5 Copayment

$5 Copayment

• Allergy serum

• 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 (see Section 5b Surgical and anesthesia services provided by physicians and other health care).

• Respiratory and inhalation therapy - outpatient rehabilitation limited to 60 visits per condition
• Cardiac rehabilitation following qualifying event/condition is provided for up to three (3) visits a week for a total of 18 visits.
• 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.)
• Applied Behavior Analysis (ABA) – Children with autism spectrum disorder (See section 5(e) for benefits)
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We 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 Other services under You need prior Plan approval for certain services in Section 3.

$60 per visit (no deductible)

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

$60 per visit (no deductible)

Note: If you receive these services during an inpatient admission or an outpatient visit, 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)

25% of our allowance

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

30% of our allowance

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

Not covered

• Long-term rehabilitative therapy
• Exercise programs

60 visits per person, per calendar year

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. Habilitative services will be subject to the same copay and visits as rehabilitative services.

• Audiological testing and medically necessary treatment for hearing problems
• Hearing testing for children through age 17 (See Preventive care, children)

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

25% of our allowance

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

30% of our allowance

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

• External hearing aids
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices

For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices

Not covered:

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

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

• Corrective eyeglasses and frames or contact lenses (hard or soft) for children through age 18 per

  24 month period.

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

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

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

$30 per visit to a primary care physician, No Deductible

$60 per visit to a specialist, No Deductible

$30 per visit to a primary care physician, No Deductible 

$60 per visit to a specialist, No Deductible 

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 or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy. External prosthetic devices, except those associated with reconstructive surgery after a mastectomy are limited to two per member per calendar year.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
• Foot Orthotics and Ankle Foot Orthotics are covered for members who have diabetes with demonstrated peripheral neuropathy or the insert is needed for a shoe that is part of a covered brace.
• Ostomy and urological supplies

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

• External hearing aids
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

We limit coverage to one (1) device per ear per every 24 months.

Note: For information on the professional charges for surgery to insert an implant, see Section 5(b) Surgical procedures. For information on the hospital and ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Dental braces, devices, and appliances
• Braces for aid in sports activities
• Internally implanted devices, equipment and prosthetics related to treatment of sexual dysfunction
• DOC Bands (Dynamic Orthotic Cranial Bands)
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Orthotics (regular or custom, including but not limited to ankle foot orthotics or podiatric orthotics)
• Repair and replacement of orthopedic and prosthetic devices, unless necessitated by normal growth
• Hearing aid batteries
• Replacement hearing aid devices within the same 24 month period
• Hearing devices that are not specifically listed in the covered services section

• Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:
• Hospital beds
• Wheelchairs (motorized wheelchairs and scooter require preauthorization)
• Crutches
• Walkers
• Audible prescription reading devices
• Speech generating devices
• Enteral feeding pumps
• Insulin pumps, and syringes for insulin pumps
• Apnea monitor
• Cane
• Ostomy and urological supplies
• Prosthetic and orthotic supplies
• Replacement due to anatomical growth
• Repair and replacement of DME determined to be medically necessary
• 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

• Blood glucose monitors for members with diabetes  

Note: Prior authorization is required for non-preferred blood glucose monitors and supplies.

Note: Call us at 800-537-9384 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Not covered:

• Comfort, convenience, or luxury items or features, including breast pumps, air conditioners, humidifiers and dehumidifiers 
• Electric monitors of bodily functions, except for apnea monitors
• Devices to perform medical testing of bodily fluids, excretions or substances
• Disposable supplies
• Electronically controlled cooling or heating compression therapy devices (such polar ice packs, Ice Man Cool  Therapy, or Cryo-cuff)
• Home traction units
• Replacement of lost equipment
• Repair, adjustment, or replacement necessitated by wear, tear or misuse
• More than one piece of durable medical equipment serving essentially the same function, except for replacement due to anatomical growth; spare equipment or alternate use equipment is not provided
• 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 1 (one) 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 (oxygen is covered under DME).

$60 per visit (no deductible)

$60 per visit (no deductible)

Not covered:

• Home care requested by, or the convenience of, the patient or the patient’s family;
• Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication;
• Home care that could appropriately be rendered in a Plan medical office, affiliated hospital, or skilled nursing facility;
• Home care that can be performed safely and effectively by people whom, in order to provide the care do not require medical licenses or certificates, or the presence of a supervising licensed nurse
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.
• 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

• Coverage limited to subluxation and manipulation
• 60 visits (visit limit includes physical and occupational therapies. See Physical and Occupational therapies)

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.  

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

$30 per visit (no deductible)

$30 per visit (no deductible)

Coverage is available for up to six (6) nutritional counseling visits with a registered dietician for any covered condition, but especially:

• High cholesterol
• Obesity
• High blood pressure
• Diabetes 

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: Over-the-counter (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 over-the-counter (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 over-the-counter (OTC) drugs and prescription drugs approved by the FDA to treat nicotine dependence.

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

• Asthma
• Cerebrovascular disease
• Congestive heart failure (CHF)
• Chronic obstructive pulmonary disease (COPD)
• Coronary artery disease
• Depression
• Cystic Fibrosis
• 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.

A comprehensive range of services, such as:

• Operative procedures
• Circumcision of a newborn
• 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)

$30 per visit to a primary care physician or OB/GYN, No Deductible

$60 per visit to a specialist, No Deductible

$30 per visit to a primary care physician or OB/GYN, No Deductible

$60 per visit to a specialist, No Deductible

• Surgical treatment of morbid obesity (bariatric surgery) – a condition that has persisted for at least two (2) years 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 two (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.

• 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:

• Must be 18 years of age
• Surgical removal of breasts for female-to-male patients
• Breast augmentation (implants/lipofilling) in male-to-female patients
• Surgical removal of uterus and ovaries in female-to-male and testes in male-to-female
• Reconstruction of external genitalia**

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

** 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.

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

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

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.

30% of our allowance

Nothing (no deductible)

Nothing (no deductible)

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)
• Surgery primarily for cosmetic purposes
• Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
• 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 anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
• 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 lymphedemas;
  • 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 forty-eight (48) hours after the procedure. 

25% of our allowance

30% of our 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
• Hair pieces

Oral surgical procedures, that are medical in nature, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures;
• Other surgical procedures that do not involve the teeth or their supporting structures; and
• Treatment of TMJ (non-dental).

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 allowance

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• TMJ related dental work

These solid organ transplants are subject to medical necessity and experimental /investigational review by the Plan. Refer to Other Services in Section 3 for prior authorization procedures. 

• 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)

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)

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

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. 

Allogeneic transplants for:

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Acute myeloid leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorder (MPDs)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic lymphoma /small lymphocytic lymphoma (CLL/SLL)*
• Hemoglobinopathy
• 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, Maroteauxlamy syndrome variants)
• Myelodysplasia/Myelodysplastic syndromes
• Paroxysmal Nocturnal Hemoglobinuria
• Phagocytic / Hemophagocytic deficiency diseases (e.g. Wiskott-Aldrich syndrome)
• Severe combined immuno-deficiency disease
• 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
• Multiple Myeloma
• Medulloblastoma 
• Neuroblastoma
• Pineoblastoma
• Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
• Waldenstrom’s macroglobulinemia

*Approved clinical trial necessary for coverage

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-myeloblative allogeneic, reduced intensity conditioning or RIC for:

• Acute lymphocytic or non-lymphocytic leukemia
• Advanced Hodgkin’s lymphoma
• Advanced non-Hodgkin’s lymphoma
• Breast Cancer
• Chronic lymphocytic leukemia
• Chronic lymphocytic lymphoma/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 Disorder (MPDs)
• Non-small lung cancer
• Ovarian cancer
• Prostate cancer
• Renal cell carcinoma
• Sarcomas
• Sickle cell anemia (pediatric only)

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 lymphoma /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

• 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

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.

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.

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 six (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.
• Any related conditions or complications for a member who is donating an organ or tissue when the recipient is not a member
• Outpatient immunosuppressive agents

Professional services provided in –

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

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.

• Office

$30 per visit to a primary care physician or OB/GYN, No Deductible

$60 per visit to a specialist, No Deductible

$30 per visit to a primary care physician or OB/GYN, No Deductible

$60 per visit to a specialist, No Deductible

Room and board, such as

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

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 or blood plasma, if not donated or replaced
• 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

Not covered:

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

• 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.

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.

25% of our allowance

30% of our 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.

25% of our allowance

30% of our allowance

Not covered:

• Service in the member’s home outside of the service area
• Any service for which the hospice does not customarily charge the member, or their family
• Independent nursing, homemaker services

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.

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

$30 per visit to a primary care physician, No Deductible

$60 per visit to a specialist, No Deductible

$30 per visit to a primary care physician, No Deductible

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

$0 per visit, No Deductible 

$0 per visit, No Deductible 

• Emergency or urgent care at an urgent care center

• Emergency care as an out-patient at a hospital (Emergency Room) including doctors' services. 

30% Coinsurance for facility and physician per visit; waived if admitted to hospital

• Emergency or urgent care at a doctor’s office

$30 per visit to a primary care physician or OB/GYN, No Deductible

$60 per visit to a specialist, No Deductible

$30 per visit to a primary care physician or OB/GYN, No Deductible

$60 per visit to a specialist, No Deductible

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

$0 per visit, No Deductible 

$0 per visit, No Deductible 

• Emergency or urgent care at an urgent care center

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

30% Coinsurance for facility and physician per visit; waived if admitted to hospital

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

Please see www.aetnafeds.com for additional details and updates on Teladoc service.

Note: Members will receive a Teladoc welcome kit explaining the benefit.

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.

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 use 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

$60 per visit, No Deductible

$60 per visit, No Deductible

• Telemedicine Behavioral Health consult

$60 per visit, No Deductible

$60 per visit, No Deductible

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

25% of our allowance

30% of our 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.

25% of our allowance

30% of our allowance

• Psychological and Neuropsychological testing 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

Inpatient services provided and billed by a hospital or other covered 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

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

25% of our allowance

30% of our allowance

• 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

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 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:

Tier 1 - $12 per Preferred Generic (PG) formulary drug (No Deductible)

Tier 2 - $50 per Preferred Brand (PB) name formulary drug (No Deductible) 

Tier 3 - $75 per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible) 

Tier 4 - 20% Coinsurance up to $200 maximum per Preferred Specialty (PSP) drug

Tier 5 - 20% Coinsurance up to a $500 maximum per Non-preferred Specialty (NPSP) drug

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

Tier 1 - $36 per Preferred Generic (PG) formulary drug (No Deductible)

Tier 2 - $150 per Preferred Brand (PB) name formulary drug (No Deductible)

Tier 3 - $225 per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible) 

Tier 4 - Not Available

Tier 5 - Not Available

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

Tier 1 - $12 per Preferred Generic (PG) formulary drug (No Deductible) 

Tier 2 - $50 per Preferred Brand (PB) name formulary drug (No Deductible)

Tier 3 - 20% Coinsurance up to $100 maximum per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible)

Tier 4 - 20% Coinsurance up to $200 maximum per Preferred Specialty (PSP) drug

Tier 5 - 20% Coinsurance up to a $500 maximum per Non-preferred Specialty (NPSP) drug

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

Tier 1 - $36 per Preferred Generic (PG) formulary drug (No Deductible)

Tier 2 - $150 per Preferred Brand (PB) name formulary drug (No Deductible)

Tier 3 - 20% Coinsurance up to $300 maximum per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible)

Tier 4 - Not Available

Tier 5 - Not Available

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 2023 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:

Tier 2 - $50 per Preferred Brand (PB) name formulary drug (No Deductible)

Tier 3 - $75 per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible) 

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

Tier 2 - $150 per Preferred Brand (PB) name formulary drug (No Deductible)

Tier 3 - $225 per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible)

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

Tier 2 - $50 per Preferred Brand (PB) name formulary drug (No Deductible) 

Tier 3 - 20% Coinsurance up to $100 maximum per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible)

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

Tier 2 - $150 per Preferred Brand (PB) name formulary drug (No Deductible)

Tier 3 - 20% Coinsurance up to $300 maximum per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible) 

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 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:

Tier 4 - 20% Coinsurance up to $200 maximum per Preferred Specialty (PSP) drug

Tier 5 - 20% Coinsurance up to a $500 maximum per Non-preferred Specialty (NPSP) drug

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

Tier 4 - 20% Coinsurance up to $200 maximum per Preferred Specialty (PSP) drug

Tier 5 - 20% Coinsurance up to a $500 maximum per Non-preferred Specialty (NPSP) 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, for up to a 30-day supply per prescription or refill:

Tier 1 - $12 per Preferred Generic (PG) formulary drug (No Deductible) 

Tier 2 - $50 per Preferred Brand (PB) name formulary drug (No Deductible)

Tier 3 - $75 per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible)

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

Tier 1 - $12 per Preferred Generic (PG) formulary drug (No Deductible) 

Tier 2 - $50 per Preferred Brand (PB) name formulary drug (No Deductible)

Tier 3 - 20% Coinsurance up to $100 maximum per covered Non-Preferred (NP) formulary (generic or brand name) drug (No Deductible)

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: http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.

Nothing

Nothing

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 or covered by the plan.
• 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, not listed as a covered benefit 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 and supplies for cosmetic purposes
• Fertility drugs
• 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.

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

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

Diagnostic

Office visit for routine oral evaluation —

limited to 1 visit per year

Bitewing X-rays — limited to 1 set of bitewing X-rays per year

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

Preventive

Prophylaxis (cleaning of teeth) — limited to 1 treatment per year

Topical application of fluoride — limited to 1 course of treatment per year to children under age 18

Space Maintainers for dependent children under age (14) and only for premature loss of primary molars

Sealants: once per lifetime for dependent children under age (15) when applied to permanent molars, with no caries (decay) or restorations on any surface, and with the occlusal surface intact

No deductible:

Nothing

No deductible:

Nothing

Not covered:

All services which are not specifically listed in this brochure.

 All charges

All charges

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Aetna Member website, our secure member self-service website, provides you with the tools and personalized information to help you manage your health. Click on your Aetna Member website from www.aetnafeds.com to register and access a secure, personalized view of your Aetna benefits.

You can:

• Review PCP selections
• Print temporary ID cards
• Download details about a claim such as the amount paid and the member’s responsibility
• Contact member services at your convenience through secure messages
• Access cost and quality information through Aetna’s transparency tools
• View and update your Personal Health Record
• Find information about the member extras that come with your plan
• Access health information through Aetna Healthwise® Knowledgebase

Registration assistance is available toll free, Monday through Friday, from 7am to 9pm Eastern Time at 800-225-3375. Register today at www.aetnafeds.com.

Provides eligible members with phone access to registered nurses experienced in providing information on a variety of health topics. 24-Hour Nurse Line is available 24 hours a day, 7 days a week. You may call 24-Hour Nurse Line at 800-556-1555.  We provide TDD service for the hearing and speech-impaired. We also offer foreign language translation for non-English speaking members. 24-Hour Nurse Line nurses cannot diagnose, prescribe medication or give medical advice.

Learn about what to expect before and after delivery, early labor symptoms, newborn care and more. We can also help you make choices for a healthy pregnancy, lower your risk for early labor, cope with postpartum depression and stop smoking. We will ask you questions to help us know you better and support you best. Enroll early and receive a reward when you sign up by the 16th week of pregnancy. To enroll in the program, call toll-free 1-800-272-3531 between 8 am and 7 pm ET.

• Call 800-537-9384 for provider information and location
• Select a doctor from 3 primary care doctors in that area
• The Plan will authorize you for one visit and any tests or X-rays ordered by that primary care physician
• You must coordinate all subsequent visits through your own participating primary care physician.

We keep you informed on a variety of issues related to your good health.  Visit our website at www.aetnafeds.com or call Member Services at 800-537-9384 for information on:

• Aetna Member website
• Healthwise® Knowledge base
• 24-Hour Nurse Line
• Hospital comparison tool and Estimate the Cost of Care tool
• Online provider directory
• Medical and Dental cost of care tools

We maintain a complete claims payment history online through our Aetna Member website. You can access your Aetna Member website at www.aetnafeds.com.

• Your balance will also be shown on your explanation of benefits (EOB) form.
• You will receive an EOB after every claim.

• Directories are available online by going to your Aetna Member website at www.aetnafeds.com
• Pricing information for medical care is available at www.aetnafeds.com
• Pricing information for prescription drugs is available at www.aetnafeds.com
• Link to online pharmacy through www.aetnafeds.com

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at  800-537-9384, or at our website at www.aetnafeds.com.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutions for itemized bills. 

Submit your claims to: 

Submit your medical, hospital, and vision claims to: Aetna, P.O. Box 14079, Lexington, KY 40512-4079

Submit your dental claims to: Aetna, P.O. Box 14094, Lexington, KY 40512-4094

Submit your pharmacy claims to: Aetna, Pharmacy Management, P.O. Box 52444, Phoenix, AZ 85072-2444

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.

We will notify you of our decision within 30 days after we receive your post-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 before the expiration of the original 30 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 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within six (6) months from the date of our decision; and

b) Send your request to us at: Aetna, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Your email address (optional), if you would like to receive our decision via email. Please note that by giving us your email, you may receive our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or,

b) Write to you and maintain our denial or,

c) 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.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision as wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM's decision via email. Please note that by providing your email address, you may receive OPM's decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who as a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your expression consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision with 60 days. There are no other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.  

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit the Aetna Federal Plans website at https://www.aetnafeds.com/NAIC.php.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, the primary Plan will process the benefit for the expenses first, up to its plan limit. If the expense is covered in full by the primary plan, we will not pay anything. If the expense is not covered in full by the primary plan, we determine our allowance. If the primary Plan uses a preferred provider arrangement, we use the lesser of the primary plan’s negotiated fee, Aetna’s Reasonable and Customary (R&C) and billed charges. If the primary plan does not use a preferred provider arrangement, we use the lesser of Aetna's R&C and billed charges. If the primary plan uses a preferred provider arrangement and Aetna does not, the allowable amount is the lesser of the primary plan's negotiated rate, Aetna's R&C and billed charges. If both plans do not use a preferred provider arrangement, we use the lesser of Aetna's R&C and billed charges.

For example, we generally only make up the difference between the primary payor's benefit payment and 100% of our Plan allowance, subject to your applicable deductible, if any, and coinsurance or copayment amounts.

When Medicare is the primary payor and the provider accepts Medicare assignment, our allowance is the difference between Medicare's allowance and the amount paid by Medicare. We do not pay more than our allowance. You are still responsible for your copayment, deductible or coinsurance based on the amount left after Medicare payment.

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE and CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment.  Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness.  However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned.  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

This Plan always pays secondary to:

• Any medical payment, PIP or No-Fault coverage under any automobile policy available to you.
• Any plan or program which is required by law.

You should review your automobile insurance policy to ensure that uncoordinated medical benefits have been chosen so that the automobile insurance policy is the primary payer.

Note: For Motor Vehicle Accidents, charges incurred due to injuries received in an accident involving any motor vehicle for which no-fault insurance is available are excluded from coverage, regardless of whether any such no-fault policy is designated as secondary to health coverage.

For a complete explanation on how the Plan is authorized to operate when others are responsible for your injuries please go to: www.aetnafeds.com.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB Plan remains as your primary coverage.  FEDVIP coverage pays secondary to that coverage.  When you enroll in a dental and/or vision plan on BENEFEDS.com, you will be asked to provide information on your FEHB Plan so that your Plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

If benefits are provided by Aetna for illness or injuries to a member and we determine the member received Workers’ Compensation benefits through the Office of Workers’ Compensation Programs (OWCP), a workers’ compensation insurance carrier or employer, for the same incident that resulted in the illness or injuries, we have the right to recover those benefits as further described below. “Workers’ Compensation benefits” includes benefits paid in connection with a Workers’ Compensation claim, whether paid by an employer directly, the OWCP or any other workers’ compensation insurance carrier, or any fund designed to provide compensation for workers’ compensation claims. Aetna may exercise its recovery rights against the member if the member has received any payment to compensate them in connection with their claim. The recovery rights against the member will be applied even though:

a) The Workers’ Compensation benefits are in dispute or are paid by means of settlement or compromise;

b) No final determination is made that bodily injury or sickness was sustained in the course of or resulted from the member’s employment;

c) The amount of Workers’ Compensation benefits due to medical or health care is not agreed upon or defined by the member or the OWCP or other Workers’ Compensation carrier; or

d) The medical or health care benefits are specifically excluded from the Workers’ Compensation settlement or compromise.

By accepting benefits under this Plan, the member or the member’s representatives agree to notify Aetna of any Workers’ Compensation claim made, and to reimburse us as described above.

Aetna may exercise its recovery rights against the provider in the event:

a) the employer or carrier is found liable or responsible according to a final adjudication of the claim by the OWCP or other party responsible for adjudicating such claims; or

b) an order approving a settlement agreement is entered; or

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide for related care as follows, if it is not provided by the clinical trial:

Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this plan.

Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.  This plan does not cover these costs.

Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials, this plan does not cover these costs.         

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-537-9384 or see our website at www.aetnafeds.com.

We do not waive any costs if the Original Medicare Plan is your primary payor.

You can find more information about how our plan coordinates benefits with Medicare by calling 800-537-9384 or see our website www.aetnafeds.com.

Please review the following examples which illustrates your cost share if you are enrolled in Medicare Parts A and B. 

High Option: EXAMPLE

Benefit Description: Deductible
High Option you pay without Medicare: $1,000 Self Only/$3,000 Self Plus One or Self and Family
High Option You pay with Medicare Parts A and B (primary): $1,000 Self Only/$3,000 Self Plus One or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
High Option you pay without Medicare: N/A
High Option You pay with Medicare Parts A and B (primary): No reimbursement

Benefit Description: Primary Care Physician
High Option you pay without Medicare: $30 per visit
High Option You pay with Medicare Parts A and B (primary): $30 per visit

Benefit Description: Specialist
High Option you pay without Medicare: $60 per visit
High Option You pay with Medicare Parts A and B (primary): $60 per visit

Benefit Description: Inpatient Hospital
High Option you pay without Medicare: 25% after deductible
High Option You pay with Medicare Parts A and B (primary): 25% after deductible

Benefit Description: Outpatient Hospital
High Option you pay without Medicare: 25% after deductible
High Option You pay with Medicare Parts A and B (primary): 25% after deductible

Benefit Description: Incentives offered
High Option you pay without Medicare: N/A
High Option You pay with Medicare Parts A and B (primary): We offer no additional incentives when a member enrolls in Medicare Part B.

You can find more information about how our plan coordinates benefits with Medicare by calling 800-537-9384.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE 800-633-4227, TTY 877-486-2048 or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan: You may enroll in our Medicare Advantage Plan and also remain enrolled in our FEHB Plan. If you are an annuitant or former spouse with FEHBP coverage and are enrolled in Medicare Parts A and B, you may enroll in our Medicare Advantage Plan if one is available in your area. Please call us at  888-788-0390. We do not waive cost-sharing for your FEHB coverage.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this Plan.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.  We do not cover these costs.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials.  This plan does not cover these costs.

See Section 4.

See Section 4. 

See Section 4. 

See Section 4.

Services or supplies that are, as determined by us, experimental. A drug, device, procedure or treatment will be determined to be experimental if:

• There is not sufficient outcome data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or
• Required FDA approval has not been granted for marketing; or
• A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or for research purposes; or
• The written protocol or protocol(s) used by the treating facility or the protocol or protocol(s) of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental or for research purposes; or
• It is not of proven benefit for the specific diagnosis or treatment of your particular condition; or
• It is not generally recognized by the Medical Community as effective or appropriate for the specific diagnosis or treatment of your particular condition; or
• It is provided or performed in special settings for research purposes.

Note: When a medical necessity determination is made utilizing the Aetna Clinical Policy Bulletins (CPBs), you may obtain a copy of the CPB through the Internet at: www.aetna.com/health-care-professionals/clinical-policy-bulletins/medical-clinical-policy-bulletins.html.

The term medical food, as defined in Section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) is “a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.” In general, to be considered a medical food, a product must, at a minimum, meet the following criteria: the product must be a food for oral or tube feeding; the product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements; and the product must be intended to be used under medical supervision.

Also known as medically necessary or medically necessary services.  “Medically necessary" 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.

Note: When a medical necessity determination is made utilizing the Aetna Clinical Policy Bulletins (CPBs), you may obtain a copy of the CPB through the Internet at: www.aetna.com/health-care-professionals/clinical-policy-bulletins/medical-clinical-policy-bulletins.html.

Plan allowance is the amount we use to determine our payment and your coinsurance for the service or supply in the geographic area where it is furnished. Plans determine their allowances in different ways. We determine our allowance as follows: We may take into account factors such as the complexity, degree of skill needed, type or specialty of the provider, range of services provided by a facility, and the prevailing charge in other areas in determining the Plan allowance for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of providers in the area.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act. 

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.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department at 800-537-9384.   You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

$30 for PCP and OB/GYN; $60 Specialist, No Deductible

32

25% of our allowable, after Deductible

60

25% of our allowable, after Deductible

61

$300 per visit, No Deductible; waived if admitted to hospital

66

$300 per visit, No Deductible; waived if admitted to hospital

66

Regular cost-sharing

69

$12/$50/$75/20%/20%, No Deductible

74

$36/$150/$225, No Deductible  

75

Nothing, No Deductible

80

Nothing, No Deductible

42

Flexible Benefits Option, 24 hour nurse line, Services for deaf and hearing impaired

82

$1,000 Self Only

$3,000 Self Plus One

$3,000 Self and Family

26

$6,000 Self Only

$10,000 Self Plus One

$10,000 Self Only and Family

27

$30 for PCP and OB/GYN; $60 Specialist, No Deductible

32

30% of our allowance, after Deductible

60

30% of our allowance, after Deductible

61

30% of our allowance, waived if admitted to hospital

66

30% of our allowance, waived if admitted to hospital

66

Regular cost-sharing

69

$12/$50/20%/20%/20%, No Deductible

74

$36/$150/20%, No Deductible

75

Nothing, No Deductible

80

Nothing, No Deductible

42

 Flexible Benefits Option, 24 hour nurse line, Services for deaf and hearing impaired.

82

$2,000 Self Only

$6,000 Self Plus One

$6,000 Self and Family

26

$6,000 Self Only

$10,000 Self Plus One

$10,000 Self and Family

27