We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

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.

Our health coverage meets the minimum value standard of 60% established by the ACA.  This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits.  The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

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

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

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

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

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

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

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

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

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

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

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

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member 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 in the chart 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 2025 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 2024 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 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

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

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

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

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

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

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

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

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

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

This Open Access Plan is available to our members in those FEHB Program 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 provider. Whether your covered services are provided by your selected primary care provider (for your PCP copay) or by any other participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.

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

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

You must receive care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance based on your benefit plan selection.  This plan is Open Access which means you may receive covered services from any participating provider without a required referral from your primary care provider. Some services may require prior approval from the Plan.

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

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

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

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

It depends on the type of care you need.  You and each family member are encouraged to choose a primary care provider.  This decision is important since your primary care provider provides or arranges for most of your health care.  You must select a Plan provider who is located in your service area as defined by your enrollment code.

Your primary care provider can be a General Practitioner, Family Practitioner, Internist, or Pediatrician.  Your primary care provider will provide most of your health care.

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

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

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

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

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

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

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our 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 cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

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

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

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

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

*For a 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

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

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

Next, provide the following information:

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

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

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

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

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours 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 claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-537-9384.  You may also call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-537-9384. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than a total of three (3) days or less for 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 hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

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.

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.  In that case, we will make all reasonable efforts to provide you with the necessary care.

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

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

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

   You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
   
   If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3. Write to you and maintain our denial.

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

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

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

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

Example: When you see a primary care provider, you pay a copayment of $25 per office visit; and when you see a specialist, you pay a copayment of $40 per office visit.

High Deductible Health Plan Example: When you see a primary care provider, you pay a copayment of $20 per office visit (after your deductible has been met). When you see a specialist, you pay a copayment of $30 per office visit (after your deductible has been met).

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments and coinsurance amounts do not count toward any deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible.

• High Option: The calendar year deductible is $50 for Self Only enrollment. The calendar year deductible is $100 Under a Self Plus One and Self and Family enrollment. 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.
• Standard Option: The calendar year deductible is $100 for Self Only enrollment. The calendar year deductible is $200 under a Self Plus One and Self and Family enrollment. 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 Deductible Health Plan: The calendar year deductible is $1,700 for individual coverage (Self Only enrollment). The calendar year deductible is $3,400 under a Self Plus One and Self and Family enrollment. Once an individual meets a deductible of $3,400 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.

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

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

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

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows: The total dollar amount allowed by the Plan for Covered Services, including the amounts payable by the Plan and payable by you.

Network Providers agree to accept our Plan allowance so if you use a network provider, you never have to worry about paying the difference between our Plan allowance and the billed amount for covered services.

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. 

High Option

After your deductible, copayments and/or coinsurance total $5,500 for Self Only or $11,000 per Self Plus One, or $11,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services for the remainder of the calendar year. 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. However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Dental services
• Infertility services covered under the medical benefit.

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

Standard Option

After your deductible, copayments and/or coinsurance total $6,000 for Self Only or $12,000 per Self Plus One or $12,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services for the remainder of the calendar year. 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. However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Infertility services covered under the medical benefit.

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

High Deductible Health Plan

After your deductibles, copayments, and/or coinsurance total $6,000 for Self Only or $12,000 per Self Plus One or $12,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services for the remainder of the calendar year. 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. 

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. 

If you have a question about when the out-of-pocket maximum is reached, please call our Customer Service Department at 800-537-9384.

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

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

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

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

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

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

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

• Healthcare FSA (HCFSA) – Reimburses an FSA participant for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, over-the-counter drugs and medications, vision and dental expenses, and much more) for their tax dependents, and their 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 a physician’s office
• Office medical evaluations, examinations, and consultations
• Second surgical or medical opinion

$25 per office visit to a primary care provider

$40 per office visit to a specialist

$25 per office visit to a primary care provider

$45 per office visit to a specialist

• In an urgent care center

• During a hospital stay
• In a skilled nursing facility

Nothing

See section 5(c) for facility charges.

15% of Plan Allowance

See section 5(c) for facility charges.

• Teladoc Health consult

• CVS Health Virtual Care™ consult

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

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

Please see  www.aetnafeds.com/tools.php.

Members will receive a welcome kit explaining the telehealth benefits.

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

Minor diagnostic tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG
• Sleep studies

Major diagnostic labs and radiology tests, such as:

• CT scans, MRIs, MRAs, and electron beam scans
• PET and SPECT scans
• Angiography, and other procedures that require vascular catheterization and/or the injection of medication, imaging contrast, or other substance
• Any radiological procedure that must be performed in conjunction with a diagnostic surgical procedure (for example: ultrasonic guidance procedures)
• Diagnostic nuclear medicine, including provision of radiopharmaceuticals for diagnostic purposes
• Cytogenetic studies

$200 copay

$250 copay

• 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.

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Adult Immunizations endorsed by the Centers for Disease Control (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/
• 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
  www.hrsa.gov/womens-guidelines 
• To build your personalized list of preventive services go to
  health.gov/myhealthfinder

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

Nothing (no deductible)

Nothing (no deductible)

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy, limited to 26 visits per person per calendar year
• Counseling programs when medically identified to support obesity prevention and management by an in-network provider

Note: For anti-obesity medications prescribed as indicated by the FDA chronic weight management guidelines, see Section 5(f), Prescription drug benefits.

Nothing (no deductible)

Nothing (no deductible)

Routine mammogram

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

Note: Any procedure injection, diagnostic service, laboratory, or X-ray service done in connection 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)

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.

All charges

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Children's immunizations endorsed by the Centers for Disease Control (CDC) including: DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html
• You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations 
• 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 26)

• Seven (7) routine exams from birth to age 12 months
• Three (3) routine exams from age 12 months to 24 months
• Three (3) routine exams from age 24 months to 36 months
• One (1) routine exam per year thereafter to age 26

Examinations such as:

• Vision Screening 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 26)

Note: Any procedure injection, diagnostic service, laboratory, or X-ray service done in connection 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)

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to comprehensive, intensive nutrition and behavioral weight-loss therapy and counseling programs under the USPSTF A and B recommendations. These programs are covered as part of prevention and treatment of obesity as follows:

• Comprehensive, intensive nutrition and behavioral weight-loss counseling therapy.
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

Nothing (no deductible)

Nothing (no deductible)

Not covered:

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

All charges

All charges

Complete maternity (obstetrical) care, such as:

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

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

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

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see Section 3 for other circumstances, such as extended stays for you or your baby.
• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period.  To enroll in the Enhanced Maternity program, call toll-free 1-800-272-3531.
• 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. 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. 
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury. Please refer to Section 5(c). Services provided by a hospital or other facility, and ambulance services for inpatient maternity benefit coverage.

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

Note: When a newborn requires definitive treatment during or after the mother's hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

No copay (no deductible) for routine prenatal care or the first postpartum care visit

$25 for PCP or $40 for specialist visit for postpartum care visits thereafter

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

No copay (no deductible) for routine prenatal care or the first postpartum care visit

$25 for PCP or $45 for specialist visit for postpartum care visits thereafter

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

Breastfeeding and lactation support, supplies and counseling for each birth

Nothing (no deductible) 

Nothing (no deductible) 

Not covered:

• Home delivery

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:

• Voluntary female sterilization
• Contraceptive counseling on an annual basis
• Surgically implanted contraceptives
• Generic injectable contraceptive drugs
• Intrauterine devices (IUDs)
• Diaphragms

Note: See additional Family Planning and Prescription drug coverage Section 5(f)

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

Visit https://www.aetnafeds.com/familyplanning.php for more information on contraception and the exception process.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

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

Nothing (no deductible)

Nothing (no deductible)

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

$25 per PCP visit

$40 for Specialist visit

$25 per PCP visit

$45 for Specialist visit

Not covered:

• Reversal of voluntary surgical sterilization
• Predictive Genetic testing and/or counseling

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

Diagnosis and treatment of infertility, such as:

• Testing for diagnosis and surgical treatment of the underlying medical cause of infertility.
• Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease.* **
• Artificial insemination (AI)* ** and monitoring of ovulation:
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
  • Intravaginal insemination (IVI)

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

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

You are eligible for covered ovulation induction medication cycles if:

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

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

Aetna’s National Infertility Unit

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

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

50% of Plan Allowance

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

50% of Plan Allowance

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

Not covered:

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

• Testing and treatment

$25 per office visit to a primary care provider

$40 per office visit to a specialist

$25 per office visit to a primary care provider

$45 per office visit to a specialist

• Allergy serum
• Allergy injections

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy

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

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 12 weeks for Phase II and Phase III combined
• Dialysis – hemodialysis and peritoneal dialysis
• Growth hormone therapy (GHT)
• Intravenous (IV) Infusion Therapy in a doctor’s office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services.)

Note: When provided in a physician’s office or in an urgent care center, the services listed above do not include the cost of injectable, implantable and IV drugs; see below for the cost of the drugs.

Note: We cover home IV infusion and antibiotic therapy administered by a home health agency under the Home health services benefit.

Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Section 3 - Other services under You need prior Plan approval for certain services.

• Applied Behavior Analysis (ABA) – Children with autism spectrum disorder (see section 5(e) for benefits)

$25 per office visit to a primary care provider

$40 per office visit to a specialist

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

$25 per office visit to a primary care provider

$45 per office visit to a specialist

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

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

• Qualified Physical therapists
• Occupational therapists

Note:  We only cover therapy when a physician:

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

Note: We cover physical and occupational therapy under the Home health services benefit when provided by a home health agency as part of an authorized home treatment plan.

$40 per office visit

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

$45 per office visit

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

• 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.

$25 per office visit

$25 per office visit

• Outpatient cardiac rehabilitation following qualifying event/condition is provided at a Plan facility for up to 12 weeks for Phase II and Phase III combined.

$40 per office visit

$45 per office visit

Not covered:

• Long-term habilitative and/or rehabilitative therapy
• Therapy that we determine will not significantly improve your condition
• Exercise programs

$40 per office visit

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

$45 per office visit

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

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

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

$25 per office visit to a primary care provider

$40 per office visit to a specialist

$25 per office visit to a primary care provider

$45 per office visit to a specialist

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

Note: 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

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

All charges over $100

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

*Note: You must pay out-of-pocket for charges above the $100 allowance and submit a claim form for reimbursement of the 10%.

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

Nothing (no deductible)

Nothing (no deductible) 

• Treatment of eye diseases and injury

$40 per Specialist office visit

$45 per Specialist office visit

Not covered:

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

$25 per office visit to a primary care provider

$40 per office visit to a specialist

$25 per office visit to a primary care provider

$45 per office visit to a specialist

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)
• Foot Orthotics 
• Podiatric shoe inserts

Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes. Limb and torso prosthetics must be preauthorized.

• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

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

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

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

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

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Replacement of prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s physical condition
• All charges over $500 for hair prosthesis

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

• Oxygen systems and oxygen tanks
• Dialysis equipment
• Hospital beds (Clinitron and electric beds must be preauthorized)
• Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
• Crutches
• Walkers
• Speech generating devices
• Blood glucose monitors
• Audible prescription reading devices
• Insulin pumps
• C-Pap machine
• 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

50% of Plan Allowance

• Oxygen concentrators
• Medically necessary accessories and supplies such as hoses, tubes, oxygen and ostomy supplies

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

Nothing

Nothing

Not covered:

• Durable medical equipment, corrective appliances, prostheses and artificial aids, including supplies and accessories, are excluded when primarily used for convenience, comfort, or in the absence of an illness or injury. Routine periodic servicing, such as cleaning and regulating is not covered.
• Replacement of durable medical equipment, prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s condition.
• Bathroom equipment such as bathtub seats, benches, rails and lifts.
• Home modifications such as stair glides, elevators and wheelchair ramps.
• Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities.
• Medical foods that do not require a prescription under Federal law even if your physician or other health care professional prescribes them 
• Nutritional supplements that are not administered by catheter or nasogastric tubes, except for oral medical foods taken for the treatment of Inborn Errors of Metabolism when administered under the direction of a physician

All charges

All charges

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

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

$40 per visit

$45 per visit

$40 per visit

$45 per visit

Not covered:

• Nursing care requested by, or for 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 primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Services provided by a family member or resident in the members 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 is limited to 20 visits per calendar year. Services include:

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

$25 per office visit to a primary care provider

$40 per office visit to a specialist

$25 per office visit to a primary care provider

$45 per office visit to a specialist

Not covered:

Any services not listed above

Biofeedback therapy for the treatment of certain conditions

• Anesthesia
• Pain relief

$25 per office visit to a primary care provider

$40 per office visit to a specialist

$25 per office visit to a primary care provider

$45 per office visit to a specialist

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

$25 per visit

$25 per visit

Not covered:

• Applied kinesiology
• Aromatherapy
• Craniosacral therapy
• Hair analysis
• Acupressure
• Naturopathic or homeopathic services
• Massage therapy
• Hypnotherapy
• Reflexology

Aetna offers disease management.  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.

Nothing (no deductible) 

Nothing (no deductible) 

Coverage is provided for:

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

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

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

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

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

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

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Removal of tumors and cysts
• Normal pre- and post-operative care by the surgeon
• Endoscopy procedures
• Biopsy procedures
• Voluntary sterilization (e.g.,vasectomy)
• Correction of congenital anomalies (see Reconstructive surgery)
• Treatment of burns
• Routine circumcision of a newborn
• Insertion of internal prosthetic devices. See Section 5(a) – Orthopedic and prosthetic devices for device coverage information 

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

$25 per office visit to a primary care provider

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care provider

$45 per office visit to a specialist

See section 5(c) for facility charges.

Surgical treatment of severe obesity (bariatric surgery) - a condition in which an individual has a body mass index (BMI) exceeding 40 or a BMI greater than 35 in conjunction with documented significant co-morbid conditions (such as coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea, nonalcoholic steatohepatitis (NASH) or refractory hypertension)**

• Members must have attempted weight loss in the past without successful long-term weight reduction; and Members must have participated in and been compliant with an intensive multicomponent behavioral intervention through a combination of dietary changes and increased physical activity for 12 or more sessions occurring within 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.

$25 per office visit to a primary care provider

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care provider

$45 per office visit to a specialist

See section 5(c) for facility charges.

Nothing (no deductible)

Nothing (no deductible)

• Gender affirming surgery* 

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

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

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

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

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

$25 per office visit to a primary care provider

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care provider

$45 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

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

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if: 
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and 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 (See Orthopedic and prosthetic devices in Section 5(a))

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

$25 per office visit to a primary care provider

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care provider

$45 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

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

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

• Treatment of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Medically necessary surgical treatment of TMJ (must be preauthorized)
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures
• Removal of bony impacted wisdom teeth

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

$25 per office visit to a primary care provider

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care provider

$45 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

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

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

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

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

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

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

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

Blood or marrow stem cell transplants

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

The Plan extends coverage for the diagnoses as indicated below.

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

*Approved clinical trial necessary for coverage.

$40 per specialist visit
See section 5(c) for facility charges.

$45 per specialist visit
See section 5(c) for facility charges.

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

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

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Non-myeloablative allogeneic, Reduced Intensity Conditioning or RIC for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MPDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas
  • 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

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

National Transplant Program (NTP) - Transplants which are non-experimental or non-investigational are a covered benefit.  Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery.  The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures.  A transplant is non-experimental and non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate for 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 screening tests and donor search expense for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

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.

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered
• Travel expenses, lodging, and meals

Professional services provided in –

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

Nothing

See section 5(c) for facility charges.

15% of Plan Allowance

See section 5(c) for facility charges.

Professional services provided in –

• Office

$25 per office visit to a primary care provider

$40 per office visit to a specialist

$25 per office visit to a primary care provider

$45 per office visit to a specialist

Room and board, such as

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

$200 per day up to a maximum of $1,000 per admission

15% of Plan Allowance

Other hospital services and supplies, such as:

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

$200 per day up to a maximum of $1,000 per admission

15% of Plan Allowance

Not covered:

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

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Radiologic procedures, diagnostic laboratory tests, and X-rays when associated with a medical procedure being done the same day
• 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

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.

$400 per visit

$650 per visit

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

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

*See below for exceptions

$40 per specialist visit

$45 per specialist visit

Complex diagnostic tests limited to:

• CT scans, MRIs, MRAs, and electron beam scans
• PET and SPECT scans
• Angiography, and other procedures that require vascular catheterization and/or the injection of medication, imaging contrast, or other substance
• Any radiological procedure that must be performed in conjunction with a diagnostic surgical procedure (for example: ultrasonic guidance procedures)
• Diagnostic nuclear medicine, including provision of radiopharmaceuticals for diagnostic purposes
• Genetic testing—diagnostic*

*Note:  These services need precertification.  See Section 3 “Services requiring 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.

$200 copay

$250 copay

Not covered:

• Personal comfort items
• Whole blood and concentrated red blood cells not replaced by the member

Skilled nursing facility (SNF) / Extended care benefits: 30 days per member per calendar year

• Professional services – physicians and general nursing care
• Medical supplies and medications
• Medical equipment ordinarily provided by a skilled nursing facility
• Room and board

Not covered:

• Custodial care, personal, comfort or convenience items

• Services for pain and symptom management
• Short-term inpatient care and procedures necessary for pain control
• Respite care may be provided only on an occasional basis and may not be provided longer than five days
• Home visits made by a physician, nurse, home health aide, social worker or therapist with no limit on number of visits
• General medical equipment and supplies related to the terminal illness

$5 copay

$15 copay

Not covered:

• Independent nursing
• Homemaker services
• Specialized, customized equipment

The plan 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

To transport a member from home to hospital for medically necessary inpatients 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 require prior approval from the Plan.

• Emergency or urgent care at a doctor’s office

$25 per PCP visit

$40 per specialist visit

$25 per PCP visit

$45 per specialist visit

• Emergency or urgent care at an urgent care center

$40 copayment per urgent care center visit

$40 copayment per urgent care center visit

• Emergency care as an outpatient at a hospital, (Emergency Room) including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

$250 copayment per visit

Not covered:

• Elective care or non-emergency care in a hospital emergency room
• Follow-up care in a hospital emergency room, unless we have given prior authorization

All charges

All charges

• Emergency or urgent care at a doctor’s office

$25 per PCP visit

$40 per specialist visit

$25 per PCP visit

$45 per specialist visit

• Emergency or urgent care at an urgent care center

$40 copayment per urgent care center visit

$40 copayment per urgent care center visit

• Emergency care as an outpatient at a hospital, (Emergency Room) including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

$250 copayment per visit

Not covered:

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

• Teladoc Health consult

• CVS Health Virtual Care™ consult

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

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

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

Members will receive a welcome kit explaining the telehealth benefits.

The plan 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
• 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

$25 per office visit 

$25 per office visit 

• Telehealth Behavioral Health consult

$25 per consult

$25 per consult

• CVS Health Virtual Care™ telehealth consult

$25 per consult

$25 per consult

• Skilled behavioral health services provided in the home, but only when all of the following criteria are met:
  • Your physician order 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 per office visit

$25 per office visit

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 per visit

$25 per visit

• 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

$25 per office visit

$25 per office visit

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

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

$200 per day up to a maximum of $1,000 per admission

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

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

$25 per office visit

$25 per office visit

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

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

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

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

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

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a).

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

$7 per Preferred Generic (PG) formulary drug;

$40 per Preferred Brand (PB) name formulary drug;

40% per covered Non-Preferred (NP) (generic or brand name) drug up to $240 maximum

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

$7 per Preferred Generic (PG) formulary drug;

$80 per Preferred Brand (PB) name formulary drug;

40% per covered Non-Preferred (NP) (generic or brand name) drug up to $720 maximum

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

$7 per Preferred Generic (PG) formulary drug;

$50 per Preferred Brand (PB) name formulary drug;

50% per covered Non-Preferred (NP) (generic or brand name) drug up to $240 maximum

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

$7 per Preferred Generic (PG) formulary drug;

$100 per Preferred Brand (PB) name formulary drug;

50% per covered Non-Preferred (NP) (generic or brand name) drug up to $720 maximum

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to FEHB/PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

Visit www.AetnaFeds.com/FamilyPlanning.php for more information on contraception and the the exception process.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5(a).

See coverage below

See coverage below

Women's contraceptive drugs and devices

• Generic oral contraceptives on our formulary list
• Generic emergency contraception, including 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 2025 Pharmacy Drug (Formulary) Guide or call 800-537-9384.

Nothing

Nothing

• 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:

$40 per Preferred Brand (PB) name formulary drug;

40% per covered Non-Preferred (NP) (generic or brand name) drug up to $240 maximum

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

$80 per Preferred Brand (PB) name formulary drug;

40% per covered Non-Preferred (NP) (generic or brand name) drug up to $720 maximum

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

$50 per Preferred Brand (PB) name formulary drug;

50% per covered Non-Preferred (NP) (generic or brand name) drug up to $240 maximum

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

$100 per Preferred Brand (PB) name formulary drug;

50% per covered Non-Preferred (NP) (generic or brand name) drug up to $720 maximum

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:

Preferred Specialty (PSP): 30% of Plan Allowance

Non-preferred Specialty (NPSP): 50% of Plan Allowance

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

Preferred Specialty (PSP): 30% of Plan Allowance

Non-preferred Specialty (NPSP): 50% of Plan Allowance

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:

$7 per Preferred Generic (PG) formulary drug;

$40 per Preferred Brand (PB) name formulary drug;

40% per covered Non-Preferred (NP) (generic or brand name) drug up to $240 maximum

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

$7 per Preferred Generic (PG) formulary drug;

$50 per Preferred Brand (PB) name formulary drug;

50% per covered Non-Preferred (NP) (generic or brand name) drug up to $240 maximum

Preventive Care 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)

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from an in-network pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections. For more information consult the FDA guidance at: https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.

Please refer to the 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. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.

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, and any food item not listed as a covered benefit, 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 section 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
• Nonprescription medications unless specifically indicated elsewhere
• Drugs to enhance athletic performance
• 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

All charges

All charges

$25 per office visit to a primary care provider

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care provider

$45 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

• Implants

Oral evaluation

• Periodic oral examination ­– one per member every six months
• Limited oral evaluation – problem focused
• Comprehensive oral evaluation

• Comprehensive periodontal evaluation

Radiographs

• Intraoral full series X-rays – one per member every three years
• Bitewing X-rays
• Panoramic X-ray – one per member every three years

Preventive

• Prophylaxis and fluoride treatment (child) – one per member every six months
• Prophylaxis (adult) – one per member every six months

• Sealant – per tooth (through age 14)

Emergency treatment - During office hours

• Palliative treatment of dental pain

Restorative

Routine fillings – Amalgam or Resin-based composite for permanent or primary teeth

Amalgam

• 1 surface

• 2 surfaces

• 3 surfaces

• 4 or more surfaces

Restorative

Routine fillings – Amalgam or Resin-based composite for permanent or primary teeth

Resin-based composite – anterior

• 1 surface

• 2 surfaces

• 3 surfaces

• 4 or more surfaces

Restorative

Routine fillings – Amalgam or Resin-based composite for permanent or primary teeth

Resin-based composite – posterior

• 1 surface

• 2 surfaces

• 3 surfaces

• 4 or more surfaces

Periodontics

Periodontal scaling and root planing – four or more teeth per quadrant

Oral surgery

Extractions (routine)

Endodontics

Pulp cap

• two canals

• three canals

Crowns – Limited to six crowns per member per year

Crown build up with pins

• Each additional tooth

Preventive appliances

Space maintainer – unilateral

The following services are limited:

• Replacement of prosthetic appliances less than five years old is covered only when good dental care dictates and such replacement is prescribed by a Plan dentist.
• Single unit gold restorations and crowns are covered only when the tooth cannot be adequately restored with other restorative materials.

Not covered:

• Implants
• Bridges
• Surgical grafting procedures
• Treatment for developmental malformations such as enamel hypoplasia and fluorosis (brown and white stains on teeth)
• Maxillary and mandibular malformations and anodontia
• General anesthetic
• Cosmetic or orthodontic treatment
• Full mouth rehabilitation, periodontal splints, restoration of tooth structure lost from attrition and restoration for misalignment of the teeth
• Dental treatment for temporomandibular (jaw) joint disorders and related diseases
• Replacement of lost or stolen dentures, bridges or other dental appliances
• Topical application of fluoride for adults

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations, tobacco/E-cigarettes cessation programs, obesity weight loss programs, disease management and wellness programs. These services are covered at 100% if you use a network provider and the services are described in Section 5 Preventive care. You do not have to meet the deductible before using these services. Preventive care does not reduce your HRA nor do you need to use your HSA for in-network preventive care.

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5.  You typically pay $20 per office visit to a primary care provider, $30 per office visit to a specialist. The Plan typically pays 90% for home care and hospital care; you typically pay 10% of the Plan allowance.

Covered services include:

• Medical services and supplies provided by physicians and other health care professionals
• Surgical and anesthesia services provided by physicians and other health care professionals
• Hospital services; other facility or ambulance services
• Emergency services/accidents
• Mental health and substance abuse benefits
• Prescription drug benefits
• Dental benefits for services related to an accidental injury.

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see  for more details).

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Services (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan.  In 2025, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $62.50 per month for a Self Only enrollment or $125.00 per month for a Self Plus One enrollment or $125.00 per month for a Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $4,300 for an Self Only enrollment and $8,550 for Self Plus One coverage and Self and Family coverage.See maximum contribution information in Section 5. Savings-HSAs and HRAs. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

• Inspira Financial provides a debit card and record- keeping services. Inspira Financial is the custodian for the HSA accounts.
• Your contributions to the HSA are tax deductible. (State taxes apply in California, Alabama and New Jersey)
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).
• Your HSA earns tax-free interest. or any investment gains through a choice of voluntary investment options. (New Hampshire and Tennessee do tax dividends and earnings on HSA’s)
• You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS publications 502 and 969 for information on eligible expenses. A link to this publication can also be found at www.AetnaFeds.com)
• Your unused HSA funds and interest accumulate from year to year.
• It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire.
• When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a Health Care Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by an HCFSA health care flexible spending account this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you.

If you are not eligible for an HSA, for example you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA.

If we determine that you are ineligible for an HSA, we will notify you by letter and provide an HRA for you.

In 2025, we will give you an HRA credit of $750 per year for a Self Only enrollment or $1,500 per year for a Self Plus One enrollment or $1,500 per year for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible.

HRA features include:

• For our HDHP option, the HRA is administered by Aetna Life Insurance Company. 
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment.
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP.
• Unused credits carryover from year to year.
• HRA credit does not earn interest.
• HRA credit is forfeited if you leave Federal employment or switch health insurance plans.
• An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements.

Your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $6,000 for Self Only enrollment, $12,000 per Self Plus One enrollment or $12,000 per Self and Family enrollment. 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. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as non-covered expenses). Refer to Section 4 Your catastrophic protection out-of-pocket maximum for more details and HDHP Section 5 Traditional medical coverage subject to the deductible for more details.

Health Reimbursement Arrangement (HRA)

Provided when you are
ineligible for an HSA

The Plan will establish an HSA for you with Inspira Financial (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS).

Aetna Life Insurance Company, Federal Plans, PO Box 818047, Cleveland, OH 44181-8047

800-537-9384 or www.aetnafeds.com

Aetna Life Insurance Company is the HRA fiduciary for this Plan.

Aetna Life Insurance Company, Federal Plans, 818047, Cleveland, OH 44181-8047 

800-537-9384 or www.aetnafeds.com

There is no HSA set-up fee.

The administrative fee is covered in the premium while the member is covered under the HDHP.

If you are no longer covered under the HDHP, there is a $5 monthly administrative fee that will be deducted from your HSA account every month.

Members will be subject to the administrative fee if they are enrolled but no longer eligible for contributions and enrolled in the HRA.

None

You must:

• Enroll in this HDHP
• Have no other health insurance coverage
• Not be enrolled in Medicare
• Not be claimed as a dependent on someone else’s tax return
• Not currently receiving VA benefits or services (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits in the last three (3) months 
• Complete and return all banking paperwork

Eligibility for contributions is determined on the first day of the month following your effective date of enrollment and will be prorated for length of enrollment.

You must enroll in this HDHP.

Eligibility is determined on the first day of the month following your effective day of enrollment and will be prorated for length of enrollment.

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month. Premium pass through contributions are based on the effective date of your enrollment in the HDHP.

Note: If your effective date in the HDHP is after the 1st of the month, the earliest your HSA will be established is the 1st of the following month.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, Etc.)

You may contribute to your HSA by setting up an electronic funds transfer from your checking or saving account up to the maximum allowed. The deadline for HSA contributions is April 15 following the year for which contributions are made. When making contributions for previous tax year, use the correct tax year if you are adding your own deposits from a linked bank account. You can obtain additional HSA forms by logging into the Member Website website at www.aetnafeds.com.

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for length of enrollment. The entire amount of your HRA will be available to you upon your enrollment.

For 2025, a monthly premium pass through of $62.50 will be made by the HDHP directly into your HSA each month.

For 2025, your HRA annual credit is $750 (prorated for mid-year enrollment).

For 2025, a monthly premium pass through of $125.00 will be made by the HDHP directly into your HSA each month.

For 2025, your HRA annual credit is $1,500 (prorated for mid-year enrollment).

For 2025, a monthly premium pass through of $125.00 will be made by the HDHP directly into your HSA each month.

For 2025, your HRA annual credit is $1,500 (prorated for mid-year enrollment).

The maximum that can be contributed to your HSA is an annual contribution of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $4,300 for Self Only coverage and $8,550 for a Self Plus One and Self and Family coverage.

If you are age 55 or older, the IRS permits you to make additional contributions to your HSA .  The allowable contributions is $1,000.  Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS website at www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS. 

Note: Annual premium pass through contributions will be forfeited if you do not open an HSA by 12/31 of that plan year.

You are eligible to fund your account up to the maximum contributions limit set by the IRS even if you have partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA.  If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death and disability.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Over age 55 additional contributions are discussed in this Section.

The full HRA credit will be available, subject to proration, on the effective date of enrollment. The HRA does not earn interest.

You may make an annual maximum contribution of $3,550.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $7,050.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $7,050.

You cannot contribute to the HRA.

You can access your HSA by the following methods:

• Debit card - The Debit Card must be activated in order to have access to HSA Funds, customer service and online information.
• The online employee portal.
• Connected Claims Option - Connected claims is a fast and easy way to pay out- of-pocket health expenses from your HSA. If you are a member of an Aetna HDHP and enrolled in an Aetna HSA you can elect to have your claims sent directly to your HSA to pay for qualified out-of-pocket expenses, paying the doctor directly, without having to use your Inspira Financial Aetna HSA MasterCard debit card.
• Direct Deposit for HSA Reimbursement - Reimbursements can now be sent electronically to personal checking or savings accounts. You can access this feature from the employee portal.

For qualified medical expenses under your HDHP, you will be automatically reimbursed when claims are submitted through the HDHP. For expenses not covered by the HDHP, such as dental services, a reimbursement form will be sent to you upon your request.

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA.

Your HSA is established the first of the month following the effective date of your enrollment in this HDHP. For most Federal enrollees (those not paid on a monthly basis), the HDHP becomes effective the first pay period in January 2025. If the HDHP is effective on a date other than the first of the month, the earliest date medical expenses will be allowable is the first of the next month. If you were covered under the HDHP in 2024 and remain enrolled in this HDHP, your medical expenses incurred January 1, 2025 or later, will be allowable.

If you incur a medical expense between your HDHP effective date but before your HSA is effective, you will not be able to use your HSA to reimburse yourself for those expenses.

Note: Plan contributions are typically deposited around the middle of each month.

See IRS Publications 502 and 969 for information on eligible medical expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.  You must submit these expenses with a claim form (available on our website www.aetnafeds.com) for reimbursement.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publications 502 and 969 for information on eligible medical expenses.  Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable.  Most other types of medical insurance premiums are not reimbursable.

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Funds are not available for withdrawal until all the following steps are completed:

• Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change),
• The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA, and  
• The fiduciary sends you HSA paperwork for you to complete and the fiduciary receives the completed paperwork back from you.
• After the plan administrator receives enrollment and contributions from OPM and your HSA has been created by Inspira Financial and funded, the enrollee can withdraw funds up to the amount contributed for any expenses incurred on or after the date the HSA was initially established.

Funds are not available until:

• Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change); and
• The entire amount of your HRA will be available to you upon your enrollment in the HDHP.  (The HRA amount will be pro-rated based on the effective date of coverage.)

You can take this account with you when you change plans, separate or retire.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

No charge

$25.00 per returned deposit check

$25.00 per returned check

$25.00 per stopped check

$25.00 per EFT deposit return

No charge

No charge

$1.50 - available online at no charge

You can open an investment account and you will be charged monthly at .03% of your investment account balance.

$25.00 per transfer

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction). You receive tax advantages in any case. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective data is after January 1st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of year of your first year of eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

If you are age 55 or older, the IRS permits you to make additional contributions to your HSA. The allowable additional contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS website at  www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676.

Spouse additional contributions must be established in a separate HSA account from that of the employee. Please contact your plan administrator for details.

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.” Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA.  Also, insurance premiums are reimbursable under limited circumstances.

You can view account activity such as the “premium pass through,” withdrawals, and interest earned on your account, as well as account balances online on Aetna Member Website. You can also request a paper monthly activity statement at an additional charge - $1.50 per month.

There is no minimum withdrawal or distribution amount.

Participation in voluntary investment options is entirely optional and neither Aetna nor Inspira Financial is or will be acting in the capacity of a registered investment advisor.

Account holders who exceed the minimum required balance of $1,000 in their HSA cash account, will have a number of different investment options to choose from in 2025 that will be offered by different organizations that have been selected by Inspira Financial. Balances in these investment options may fluctuate up or down and will not be insured by the FDIC or other government agencies.

Inspira Financial will make available HSA investment options, as defined below, to account holders who exceed the minimum required balance of $1,000 in their HSA cash account. (Investment options are subject to change).

These funds are distributed through BNY Mellon and are not offered or insured by

Inspira Financial or BNY Mellon. Participation in these options will be entirely optional, and neither Inspira Financial or BNY Mellon is or will be acting in the capacity of a registered investment advisor with respect to these options. Balances in the funds may fluctuate and will not be insured by the FDIC or other government agency.

Investment Options

Equity funds

• JPMorgan Large Cap Growth Fund - Select Class
• Schwab Fundamental US Large Company Index Fund
• Davis New York Venture Fund Class Y
• Vanguard 500 Index Admiral
• Vanguard Dividend Appreciation Index Admiral
• Invesco-Oppenheimer Main St Fund^® CIY
• Parnassas Mid Cap Fund Institutional Shares
• American Century Investments^® Mid Cap Value Fund Class 1
• Artisan Small Cap Fund Institutional Shares
• Vanguard Small-Cap Index Admiral
• Dodge & Cox International Stock Fund
• Thornburg International Value Fund Class I
• Vanguard Developed Markets Index Admiral
• Vanguard Emerging Markets Stock Index Admiral

Bond Funds

• American Funds Inflation Linked Bond R6
• BlackRock Strategic Income Opportunities Institutional
• Dodge & Cox Income Fund
• MetWest Total Return Bond Fund Class M

Other Funds

• American Funds 2020 Target Date Retire R6
• American Funds 2025 Target Date Retire R6
• American Funds 2030 Target Date Retire R6
• American Funds 2035 Target Date Retire R6
• American Funds 2040 Target Date Retire R6
• American Funds 2045 Target Date Retire R6
• American Funds 2050 Target Date Retire R6
• American Funds 2055 Target Date Retire R6
• American Funds 2060 Target Date Retire R6
• Vanguard LifeStrategy Conservative Growth Investor
• Vanguard LifeStrategy Moderate Growth Investor

Please review the chart in Section 5. Savings-HSAs and HRAs which details the differences between an HRA and an HSA. The major differences are:

• you cannot make contributions to an HRA
• funds are forfeited if you leave the HDHP
• an HRA does not earn interest
• HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP. HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP. FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

• 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.

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations 
• Adult Immunizations endorsed by the Centers for Disease Control (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/
• 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.hrsa.gov/womens-guidelines 
• 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 800-537-9384 for information on whether a specific test is considered routine.

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.

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy, limited to 26 visits per person per calendar year
• Counseling programs when medically identified to support obesity prevention and management by an in-network provider

Note: For anti-obesity medications prescribed as indicated by the FDA chronic weight management guidelines, see Section 5(f), Prescription drug benefits.

Nothing

Routine mammogram

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

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

Children's immunizations endorsed by the Centers for Disease Control (CDC) including: DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html

You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

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 26)
  • Seven (7) routine exams from birth to age 12 months
  • Three (3) routine exams from age 12 months to 24 months
  • Three (3) routine exams from age 24 months to 36 months
  • One (1) routine exam per year thereafter to age 26
• Examinations such as:
  • Vision Screening 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 26)
    

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.

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to comprehensive, intensive nutrition and behavioral weight-loss therapy and counseling programs under the USPSTF A and B recommendations.  These programs are covered as part of prevention and treatment of obesity as follows:

Comprehensive, intensive nutrition and behavioral weight-loss counseling therapy, unlimited visits per person per calendar year.

 Counseling programs when medically identified to support obesity prevention and management by an in-network provider.

Nothing

Not covered

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

All charges

100% of allowable charges until you meet the deductible of $1,700 per person, $3,400 per Self Plus One enrollment or $3,200 per Self and Family enrollment.

Professional services of physicians

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

$20 per office visit to a primary care provider

$30 per office visit to a specialist

• In an urgent care center

• During a hospital stay
• In a skilled nursing facility

• Teladoc Health consult

• CVS Health Virtual Care™

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

Please see www.AetnaFeds.com/Tools.php for information on medical and behavioral telehealth services.

Members will receive a welcome kit explaining the telehealth benefits.

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

Minor diagnostic tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG

Major diagnostic labs and radiology tests, such as:

• CT scans, MRIs, MRAs, and electron beam scans
• PET and SPECT scans
• Angiography, and other procedures that require vascular catheterization and/or the injection of medication, imaging contrast, or other substance
• Any radiological procedure that must be performed in conjunction with a diagnostic surgical procedure (for example: ultrasonic guidance procedures)
• Diagnostic nuclear medicine, including provision of radiopharmaceuticals for diagnostic purposes
• Cytogenetic studies

$175 copay

Complete maternity (obstetrical) care, such as:

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

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

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

• Screening for gestational diabetes 
• Delivery
• Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.

As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period. To enroll in the Enhanced Maternity program, call toll-free 1-800-272-3531.

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 cover an extended inpatient stay if medically necessary but you, your representatives, your doctor, or your hospital must recertify the extended stay.

We cover routine nursery care of the newborn child during the covered portion of the mother’s hospital stay. 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. 

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

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

No copay (no deductible) for routine prenatal care or the first postpartum care visit

10% of Plan Allowance

Screening for gestational diabetes for pregnant women

Nothing (no deductible)

Breastfeeding and lactation support, supplies and counseling for each birth

Nothing (no deductible)

Not covered:

• Routine sonograms to determine fetal age, size or sex
• Home delivery

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes: 

• Voluntary female sterilization
• Contraceptive counseling on an annual basis
• Surgically implanted contraceptives
• Intrauterine devices (IUDs)
• Generic injectable contraceptive drugs 
• Diaphragms

Note: See additional Family Planning and Prescription drug coverage Section 5(f)

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

Visit www.AetnaFeds.com/FamilyPlanning.php for more information on the contraception process.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Nothing

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

$20 per PCP visit

$30 for Specialist visit

• Generic injectable contraceptive drugs 

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.

Not covered:

• Reversal of voluntary surgical sterilization
• Predictive genetic testing and/or genetic counseling.

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

Diagnosis and treatment of infertility, such as:

• Testing for diagnosis and surgical treatment of the underlying medical cause of infertility.
• Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease.* **
• Artificial insemination (AI)* ** and monitoring of ovulation:
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
  • Intravaginal insemination (IVI)

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

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

You are eligible for covered ovulation induction medication cycles if:

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

Note: Please see Section 5(f) for coverage of infertility drugs.

Aetna’s National Infertility Unit

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

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

Not covered:

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

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

• Testing and treatment

$20 per office visit to a primary care provider

$30 per office visit to a specialist

• Allergy serum
• Allergy injections

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy

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

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 12 weeks for Phase II and Phase III combined
• Dialysis – hemodialysis and peritoneal dialysis
• Growth hormone therapy (GHT)
• Intravenous (IV) Infusion Therapy in a doctor’s office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services.)

Note: When provided in a physician’s office or in an urgent care center, the services listed above do not include the cost of injectable, implantable and IV drugs; see below for the cost of the drugs.

Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that be determine are medically necessary.  See Section 3. How you get care - Other services.

Note: We cover home IV infusion and antibiotic therapy administered by a home health agency under the Home health services benefit.

• Applied Behavior Analysis (ABA) - Children with autism spectrum disorder (see section 5(e) for benefits)

$20 per office visit to a primary care provider

$30 per office visit to a specialist

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

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

• Qualified Physical therapists
• Occupational therapists

Note:  We only cover therapy when a physician:

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

Note: We cover physical and occupational therapy under the Home health services benefit when provided by a home health agency as part of an authorized home treatment plan

$30 per office visit

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

• 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.

$20 per office visit

• Outpatient cardiac rehabilitation following a qualifying event/condition is provided at a Plan facility for up to 12 weeks for Phase II and Phase III combined

Not covered:

• Long-term habilitative and rehabilitative therapy
• Therapy that we determine will not significantly improve your condition
• Exercise programs

60 visits per person per calendar year

Note: We cover speech therapy under the Home health services benefit when provided by a home health agency as part of an authorized home treatment plan.

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

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

$20 per office visit to a primary care provider

$30 per office visit to a specialist

• 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

Not covered:

• Hearing services that are not shown as covered

• 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.*

*Note: You must pay for charges above the $100 allowance and submit a claim form for reimbursement of the 10%.

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

• Treatment of eye diseases and injury

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

$20 per office visit to a primary care provider

$30 per office visit to a specialist

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)
• Foot Orthotics
• Podiatric shoe inserts

Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes. Limb and torso prosthetics must be preauthorized.

• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

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

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

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

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

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Replacement of prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s physical condition
• All charges over $500 for hair prosthesis

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

• Oxygen systems and oxygen tanks
• Dialysis equipment
• Hospital beds (Clinitron and electric beds must be authorized)
• Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
• Crutches
• Walkers
• Speech generating devices
• Blood glucose monitors
• Audible prescription reading devices
• Insulin pumps
• C-Pap machine
• Medical foods taken for the treatment of Inborn Errors of Metabolism when provided by a participating DME provider and administered under the direction of a physician

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

• Oxygen concentrators; and
• Medically necessary accessories and supplies such as hoses, tubes, oxygen and ostomy supplies

Not covered:

• Durable medical equipment, corrective appliances, prostheses and artificial aids, including supplies and accessories, are excluded when primarily used for convenience, comfort, or in the absence of an illness or injury. Routine periodic servicing, such as cleaning and regulating is not covered.
• Replacement of durable medical equipment, prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s condition.
• 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 care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide. Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less.  The plan will allow up to 60 visits per member per calendar year.  Your Plan Physician will periodically review the program for continuing appropriateness and need.
• Services include oxygen therapy

$20 per visit

Intravenous (IV) Infusion Therapy and medications

$30 per visit

Not covered:

• Nursing care requested by, or for 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 primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Services provided by a family member or resident in the members 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 is limited to 20 visits per calendar year. Services include:

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

Not covered:

Any services not listed above

Biofeedback therapy for the treatment of certain conditions

• Anesthesia
• Pain Relief

$20 per office visit to a primary care provider

$30 per office visit to a specialist

See section 5(c) for facility charges.

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

$20 per visit

Not covered:

• Applied kinesiology
• Aromatherapy
• Craniosacral therapy
• Hair analysis
• Acupressure
• Naturopathic or homeopathic services
• Massage therapy
• Hypnotherapy
• Reflexology

Aetna offers disease management.  Included are programs for:

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

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

Nothing (no deductible) 

Coverage is provided for:

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

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

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

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

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Removal of tumors and cysts
• Normal pre- and post-operative care by the surgeon
• Endoscopy procedures
• Biopsy procedures
• Voluntary sterilization for men (e.g., vasectomy)
• Correction of congenital anomalies (see Reconstructive surgery)
• Treatment of burns
• Routine circumcision of a newborn
• Insertion of internal prosthetic devices. See Section 5(a) – Orthopedic and prosthetic devices for device coverage information .

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

$20 per office visit to a primary care provider

$30 per office visit to a specialist

See section 5(c) for facility charges.

Nothing (no deductible)

Surgical treatment of severe obesity (bariatric surgery) - a condition in which an individual has a body mass index (BMI) exceeding 40 or a BMI greater than 35 in conjunction with documented significant co-morbid conditions (such as coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea, nonalcoholic steatohepatitis (NASH) or refractory hypertension).**

• Members must have attempted weight loss in the past without successful long-term weight reduction; and Members must have participated in and been compliant with an intensive multicomponent behavioral intervention through a combination of dietary changes and increased physical activity for 12 or more sessions occurring within 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.

$20 per office visit to a primary care provider

$30 per office visit to a specialist

See section 5(c) for facility charges.

• Gender affirming surgery* 

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

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

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

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

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

$20 per office visit to a primary care provider

$30 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

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

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and 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 (See Orthopedic and prosthetic devices in Section 5(a))

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

$20 per office visit to a primary care provider

$30 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

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

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

• Treatment of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Medically necessary surgical treatment of TMJ (must be preauthorized)
• 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
• Removal of bony impacted wisdom teeth

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

$20 per office visit to a primary care provider

$30 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

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

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

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

$30 per specialist visit

See section 5(c) for facility charges.

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

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

$30 per specialist visit

See section 5(c) for facility charges.

Blood or marrow stem cell transplants

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

The Plan extends coverage for the diagnoses as indicated below.

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