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

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

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• Well woman care 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 Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 40% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (Section 5). However, you may elect to use your HSA account to pay the bill, up to your HSA balance.

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available HRA Fund balance. Charges above the available HRA Fund balance, according to the Traditional medical coverage (Section 5), and the deductible.

Routine mammogram - covered for women

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

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 40% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (Section 5). However, you may elect to use your HSA account to pay the bill, up to your HSA balance.

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available HRA Fund balance. Charges above the available HRA Fund balance, according to the Traditional medical coverage (Section 5), and the deductible.

• The following exams and eyewear limited to:
  • One (1) routine eye exam every 12 months
  • One (1) routine hearing exam every 24 months
• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.
  

Note: Some tests provided during a routine physical may not be considered preventive. Contact Member Services at 888-238-6240 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.

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 40% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (Section 5). However, you may elect to use your HSA account to pay the bill, up to your HSA balance.

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available HRA Fund balance. Charges above the available HRA Fund balance, according to the Traditional medical coverage (Section 5), and the deductible.

Not covered:

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

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html 
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org
• Well-child care charges for routine examinations, immunizations and care (up to age 22)
  • 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 22
• Hearing loss screening of newborns provided by a participating hospital before discharge
• One (1) routine eye exam every 12 months through age 17 to determine the need for vision correction
• One (1) routine hearing exam every 24 months through age 17 to determine the need for hearing correction

Note: Some tests provided during a routine physical may not be considered preventive. Contact Member Services at 888-238-6240 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.

In-network: Nothing at a network provider

Out-of-network: All charges until you satisfy your deductible, then 40% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (Section 5). However, you may elect to use your HSA account to pay the bill, up to your HSA balance.

In-network: Nothing at a network provider

Out-of-network: Nothing at a non-network provider up to your available HRA Fund balance. Charges above the available HRA Fund balance, according to the Traditional medical coverage (Section 5), and the 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

Preventive care limited to:

• Prophylaxis (cleaning of teeth – limited to two (2) treatments per calendar year)
• Fluoride applications (limited to one (1) treatment per calendar year for children under age 16)
• Sealants – (once every three (3) years, from the last date of service, on permanent molars for children under age 16)
• Space maintainer (primary teeth only)
• Bitewing X-rays (one (1) set per calendar year)
• Complete series X-rays (one complete series every three (3) years)
• Periapical X-rays
• Routine oral evaluations (limited to two (2) per calendar year)

Note: Participating network PPO dentists may offer members services at discounted fees. Discounts may not apply in all states. So, you may be charged less for your dental care when you visit a participating network PPO dentist. Refer to our online provider directory at www.aetnafeds.com to find a participating network PPO dentist, or call Member Services at 888-238-6240.

In-network: Nothing at a network dentist

Out-of-network: All charges

In-network: Nothing at a network dentist

Out-of-network: All charges

You must satisfy your deductible before your Traditional medical coverage begins. The Self, Self Plus One and Self and Family deductible can be satisfied by one or more family members.

Once your Traditional medical coverage begins, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions, until you reach the annual catastrophic protection out-of-pocket maximum. At that point, we pay eligible medical expenses for the remainder of the calendar year at 100%.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

100% of allowable charges until you meet the deductible:

In-network: $1,800 for Self Only enrollment, $3,600 for Self Plus One enrollment and $3,600 for Self and Family enrollment or

Out-of-Network: $2,600 per Self Only enrollment, $5,200 for Self Plus One enrollment or $5,200 per Self and Family enrollment. You can use your HSA to help satisfy your deductible.

100% of allowable charges until you meet the deductible:

In-network: $1,800 for Self Only enrollment, $3,600  for Self Plus One enrollment and $3,600 for Self and Family enrollment or

Out-of-Network: $2,600 per Self Only enrollment, $5,200 for Self Plus One enrollment or $5,200 per Self and Family enrollment. Your HRA Fund counts towards your deductible.

Your HRA fund ($800/$1,600) is used first. Then you must pay the remainder of the deductible (e.g. In-network $1,600/$3,200 ) out-of-pocket i.e., $800/$1,600.

Professional services of physicians

• In physician’s office
  • Office medical evaluations, examinations and consultations
  • Second surgical or medical opinion
  • Initial examination of a newborn child covered under a Self Plus One or Self and Family enrollment
• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• At home

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

• Teladoc Consult

Please see www.aetnafeds.com for information on Teladoc service.

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

Note: Teladoc is not available for phone service in Idaho (video consult only).

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

In-network: $40 until the deductible is met, 15% of the $40 consult fee thereafter.

Out-of-network: No benefit. Must use Teladoc provider.

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• CT Scans/MRI*
• Ultrasound
• Electrocardiogram and electroencephalogram (EEG)

*Note:  CT Scans and MRIs require precertification see "Services requiring our prior approval" on pages 25-27.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

*Note:  Requires precertification.  See "Services requiring our prior approval" on pages 25-27.

In-network: Nothing at a network provider

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Complete maternity (obstetrical) care, such as:

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

Note: Items not considered routine include (but 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 for pregnant women 
• Delivery
• Postnatal care

Note: Here are some things to keep in mind:

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

You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will 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 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. Surgical benefits, not maternity benefits, apply to circumcision.

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

In-network: No coinsurance for routine prenatal care or the first postpartum care visit when services are rendered by an in-network delivering health care provider, 15% of our Plan allowance for postpartum care visits thereafter.

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: Nothing at a network provider

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

A range of voluntary family planning services for women, limited to:

• Contraceptive counseling on an annual basis
• Voluntary sterilization (See Surgical procedures (Section 5b)
• Surgically implanted contraceptives
• Generic injectable contraceptive drugs
• Intrauterine devices (IUDs)
• Diaphragms

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

Nothing for women

For men:

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling   

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

Diagnosis and treatment of infertility such as:

• Testing for diagnosis and surgical treatment of the underlying medical cause of infertility. 

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Any assisted reproductive technology (ART) procedure or services related to such procedures, including but not limited to in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and intra-cytoplasmic sperm injection (ICSI) or
• Artificial insemination (AI) and monitoring of ovulation:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI) or
• Any charges associated with care required to obtain Artificial insemination or ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for any Artificial insemination or ART procedures
• Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services
• Services and supplies related to the above mentioned services, including sperm processing
• 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 sterilization surgery
• Treatment for infertility when the cause of the infertility was a previous sterilization with or without surgical reversal
• Injectable fertility drugs, including but not limited to menotropins, hCG, GnRH agonists, and IVIG
• 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

• Testing and treatment
• Allergy injections
• Allergy serum

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Provocative food testing and sublingual allergy desensitization

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 70.

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

Note: We cover growth hormone injectables under the prescription drug benefit.

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

Note:  Applied Behavior Analysis (ABA) – Children with autism spectrum disorder is covered under mental health. (See Section 5(e) for benefits)

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

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

• Qualified Physical therapists
• Occupational therapists

Note: We only cover therapy when a physician

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

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

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

Not covered:

• Long-term rehabilitative therapy

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Habilitative services for 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 ability to function. Services include occupational therapy, physical therapy and speech therapy.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

• 60 visits per person, per calendar year.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

• Hearing exams for children through age 17 (as shown in Preventive Care, children)
• One hearing exam every 24 months for adults (see In-Network Medical Preventive Care, adult)
• Audiological testing and medically necessary treatments for hearing problems. 

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• All other hearing testing and services that are not shown as covered
• Hearing aids, testing and examinations for them

• Treatment of eye diseases and injury

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

• One (1) routine eye exam (including refraction) every 12-month period (See In-Network Medical Preventive Care)

In-network: Nothing

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

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

Note:  You must pay for charges above the $100 allowance and submit a claim form for reimbursement of the 15%.  

85% of charges after $100 

Not covered:

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

• Orthopedic devices such as braces and corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome and prosthetic devices such as artificial limbs and eyes
• 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 and surgically implanted breast implant following mastectomy, and lenses following cataract removal.  See Section 5(b) for coverage of the surgery to insert the device.
• Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

Note:  Plan lifetime maximum of $500.

In-network:  15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Orthopedic and corrective shoes not attached to a covered brace
• Arch supports
• Foot orthotics
• Heel pads and heel cups
• Podiatric shoe inserts
• Lumbosacral supports
• All charges over $500 for hair prosthesis

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Contact Plan at 888-238-6240 for specific covered DME. Some covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds (Clinitron and electric beds must be preauthorized)
• Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
• Crutches
• Walkers
• Insulin pumps and related supplies such as needles and catheters
• Certain bathroom equipment such as bathtub seats, benches and lifts

Note: Some DME may require precertification by you or your physician.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• 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
• Elastic stockings and support hose

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

Acupuncture - when provided as anesthesia for covered surgery

Note:  See page 76 for our coverage of acupuncture when provided as anesthesia for covered surgery.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

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

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

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

To request more information on our disease management programs, call 888-238-6240.

Coverage is provided for:

• Tobacco cessation programs, including individual group/phone counseling, and for physician prescribed 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.

In-network: 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.

Out-of-network: Nothing up to our Plan allowance for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year. Nothing up to our Plan allowance for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid 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.

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

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

• Voluntary sterilization for men (e.g., vasectomy)
• Treatment of burns
• Skin grafting and tissue implants
• Gender reassignment surgery*
  • The Plan will provide coverage for the following when the member meets Plan criteria:
    • Surgical removal of breasts for female-to-male patients
    • Surgical removal of uterus and ovaries in female-to-male and testes in male-to-female
    • Reconstruction of external genitalia**

*Subject to medical necessity

** Note: Requires Precertification. See “Services requiring our prior approval” on pages 25-27. 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 888-238-6240.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Nothing (no deductible)

Not covered:

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

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form and for which the disfigurement is not associated with functional impairment, except repair of accidental injury

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

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

Note: When requesting oral and maxillofacial services, please check our online provider directory or call Member Services at 888-238-6240 for a participating oral and maxillofacial surgeon.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on pages 25-27.

• 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)

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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)

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Blood or marrow stem cell transplants

Physicians measure many features of leukemia or lymphoma cells to gain insight into its aggressiveness or likelihood of response to various therapies. Some of these include the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells can grow. These analyses may allow physicians to determine which diseases will respond to chemotherapy or which ones will not respond to chemotherapy and may rather 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 non-Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)*
  • Hemoglobinopathies
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow Failure and Related Disorders (i.e. Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer*
  • Ependymoblastoma
  • Epithelial ovarian cancer*
  • Ewing's sarcoma
  • Multiple myeloma
  • Medulloblastoma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

*Approved clinical trial necessary for coverage.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• 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
  • Neuroblastoma

In network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

These blood or marrow stem cell transplants covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols.

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
• Mini-transplants (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 (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms) 
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin lymphoma) 
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

• 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. To receive in-network benefits the transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures. A transplant is non-experimental and non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate treatment for your specific condition. Coverage for a transplant where you are the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.

*Note: Transplants must be performed at hospitals designated as Institutes of Excellence (IOE).  Hospitals in our network, but not designated as IOE hospitals will be covered at the out-of-network benefit level.

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

Clinical trials must meet the following criteria:

A. The member has a current diagnosis that will most likely cause death within one (1) 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 (2) 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.

In-network: 15% of our Plan allowance
Out-of-network: 40% of our Plan allowance
and any difference between our allowance and
the billed amount.

Not covered:

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Room and board, such as

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Other hospital services and supplies, such as:

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Whole blood and concentrated red blood cells not replaced by the member
• Non-covered facilities, such as nursing homes, schools
• Custodial care, rest cures, domiciliary or convalescent cares
• Personal comfort items, such as a phone, television, barber service, 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
• Pathology Services
• Administration of blood, blood plasma, and other biologicals
• Blood products, derivatives and components, artificial blood products and biological serum
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.

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

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

Note: In-network preventive care services are not subject to coinsurance listed.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

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

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

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

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

• Emergency or urgent care at a doctor’s office
• Emergency or urgent care at an urgent care center
• Emergency care as an outpatient in a hospital, including doctors' services

In-network: 15% of our Plan allowance

Out-of-network:  15% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Elective or non-emergency care

• Teladoc consult

Please see www.aetnafeds.com for information on Teladoc service.

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

Note: Teladoc is not available for phone service in Idaho (video consult only).

In-network: $40 until the deductible is met, 15% of the $40 consult fee thereafter.

Out-of-network: No benefit. Must use Teladoc provider.

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

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

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

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

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

Note: Air ambulance may be covered. Prior approval is required.

In-network: 15% of our Plan allowance

Out-of-network: 15% of our Plan allowance and any difference between our allowance and the billed amount.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between out allowance and the billed amount.

Telemedicine Behavioral Health consult

In-network: 15% of our Plan allowance

Out-of-network: Not covered

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between out allowance and the billed amount.

Applied Behavior Analysis (ABA)

We cover 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 “Services requiring our prior approval” on pages 25-27. 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 888-238-6240.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between out allowance and the billed amount.

• 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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between out allowance and the billed amount.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between out allowance and the billed amount.

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
• Treatment of withdrawal symptoms
• Electro-convulsive therapy (ECT)
• Mental health injectables
• Substance abuse injectables
• Transcranial magnetic stimulation (TMS)

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between out allowance and the billed amount.

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

We cover the following medications and supplies prescribed by your licensed attending physician or dentist and obtained from a Plan pharmacy or through our mail order program or an out-of-network retail pharmacy:

• Drugs and medicines approved by the U.S. Food and Drug Administration for which a prescription is required by Federal law, except those listed as Not covered
• Self-injectable drugs
• Diabetic supplies limited to:
  • Lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips
  • Insulin
  • Disposable needles and syringes for the administration of covered medications
• Prenatal vitamins (as covered under the Plan’s formulary)

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.

In-network:

The full cost of the prescription is applied to the deductible before any benefits are considered for payment under the pharmacy plan. Once the deductible is satisfied, the following will apply:

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

$10 per covered generic formulary drug;

50% up to $200 maximum per covered brand name formulary drug;

50% up to $300 maximum per covered non-formulary (generic or brand name) drug.

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

$20 per covered generic formulary drug

50% up to $400 maximum per covered brand name formulary drug;

50% up to $600 maximum per covered non-formulary (generic or brand name) drug.

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

Women's contraceptive drugs and devices

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

In-network: Nothing

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

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

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

50% up to $200 maximum per covered brand name formulary drug;

50% up to $300 maximum per covered non-formulary (generic or brand name) drug.

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

50% up to $400 maximum per covered brand name formulary drug;

50% up to $600 maximum per covered non-formulary (generic or brand name) drug.

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

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 page 88, Specialty Drugs for more information or visit: www.aetnafeds.com/pharmacy.

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

Preferred:  50% up to a $350 maximum

Non-preferred: 50% up to $700 maximum

Limited benefits:

• Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period.  Note: Mail order is not available.

In-network:

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

$10 per covered generic formulary drug;

50% up to $200 maximum per covered brand name formulary drug;

50% up to $300 maximum per covered non-formulary (generic or brand name) drug.

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

Medications to promote better health as recommended by ACA.

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

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

• Aspirin
• Folic acid supplements
• Oral Fluoride
• Statins
• Breast Cancer Prevention drugs

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

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

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

Not covered:

• Drugs used for the purpose of weight reduction, such as appetite suppressants
• Drugs for cosmetic purposes, such as Rogaine
• Drugs to enhance athletic performance
• Medical supplies such as dressings and antiseptics
• 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.
• Lost, stolen or damaged drugs
• Vitamins (including prescription vitamins), nutritional supplements, and any food item, including infant formula, medical foods and other nutritional items not listed as a covered benefit, even if it is the sole source of nutrition unless otherwise stated.
• Prophylactic drugs including, but not limited to, anti-malarials for travel
• Fertility drugs
• Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen.
• Compounded thyroid hormone therapy

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program. (See page 66). 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.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

page 37

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

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

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/ 
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• Well woman care 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 Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above your Medical Fund are subject to your deductible until satisfied and then subject to Traditional medical coverage (see Section 5).

Routine mammogram - covered for women

• One (1) every calendar year; or when medically necessary
• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.
  
• The following exams limited to:
  • One (1) routine eye exam every 12 months
  • One (1) routine hearing exam every 24 months

Note: Some tests provided during a routine physical may not be considered preventive. Contact Member Services at 888-238-6240 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.

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above your Medical Fund are subject to your deductible until satisfied and then subject to Traditional medical coverage (see Section 5).

Not covered:

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

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org.
• Well-child care charges for routine examinations, immunizations and care (up to age 22)
  • 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 22
• Hearing loss screening of newborns provided by a participating hospital before discharge
• One (1) routine hearing exam every 24 months through age 17 to determine the need for hearing correction
• One (1) routine eye exam every 12 months through age 17 to determine the need for vision correction

Note: Some tests provided during a routine physical may not be considered preventive. Contact Member Services at 888-238-6240 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.

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above your Medical Fund are subject to your deductible until satisfied and then subject to Traditional medical coverage (see Section 5).

Not covered:

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

A Medical Fund is provided by the Plan for each enrollment. Each year the Plan adds to your account. For 2021, the Medical Fund is:

• $900 per year for a Self Only enrollment, or;
• $1,800 per year for a Self Plus One enrollment, or;
• $1,800 per year for a Self and Family enrollment.

The Medical Fund covers eligible expenses at 100%. For example, if you are ill and go to a network doctor for a $75 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your Medical Fund; you pay nothing.

Balance in Medical Fund for Self Only $900

Less: Cost of visit                                    - 75

Remaining Balance in Medical Fund    $825

Medical Fund expenses are the same medical, surgical, hospital, emergency, mental health and substance abuse, and prescription drug services and supplies covered under the Traditional medical coverage (see Section 5 for details).

To make the most of your Medical Fund, you should:

• Use the network providers whenever possible; and
• Use generic prescriptions whenever possible

Medical Fund Rollover

Provided you remain enrolled in this Option, any unused, remaining balance in your Medical Fund at the end of the calendar year may be rolled over to subsequent years.

Note: This rollover feature can increase your Medical Fund in the following year(s) up to a maximum rollover of $5,000 Self Only enrollment, $10,000 Self Plus One enrollment or $10,000 Self and Family enrollment.

Not covered:

• Non-network preventive care services not included under Section 5
• Services or supplies shown as not covered under Traditional medical coverage (see Section 5)
• Charges of non-network providers that exceed our Plan allowance.

Once your Medical Fund has been exhausted, you must satisfy your deductible before your Traditional medical coverage begins. The Self Plus One or Self and Family deductible can be satisfied by one or more family members.

100% of allowable charges until you meet the deductible of $1,600 per Self Only enrollment, $3,200 per Self Plus One enrollment or $3,200 per Self and Family enrollment in-network and $1,600 for Self Only, $3,200 for Self Plus One and $3,200 for Self and Family enrollment out-of-network. The deductibles for in-network and out-of-network do not cross apply and will need to be met separately for traditional benefits to begin.

(Note: If you are enrolled in Medicare Part A and B and Medicare is primary, we will waive the deductible)

Professional services of physicians

• In physician’s office
  • Office medical evaluations, examinations and consultations
  • Second surgical or medical opinion
  • Initial examination of a newborn child covered under a Self Plus One or Self and Family enrollment

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• At home

In-network: 20% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: 0% of our Plan allowance

• Teladoc Consult

Please see www.aetnafeds.com for information on Teladoc service.

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

Note: Teladoc is not available for phone service in Idaho. (video consult only).

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

In-network: $40 until the deductible is met, 20% of the $40 consult fee thereafter.

Out-of-network: No benefit. Must use Teladoc provider.

In-network: 0% per consult

Out-of-network: No benefit. Must use Teladoc provider.

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• CT Scans/MRI*
• Ultrasound
• Electrocardiogram and electroencephalogram (EEG)

* Note: CT Scans and MRIs require precertification, see "Services requiring our prior approval" on pages 25-27.

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

In-network: 20% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

In-network: 0% of our Plan allowance

Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.

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

*Note: Requires precertification. See "Services requiring our prior approval" on pages 25-27.

In-network: Nothing at a network provider

In-network: Nothing at a network provider

Complete maternity (obstetrical) care, such as:

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

 Note: Items not considered routine include (but 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 for pregnant women
• Delivery
• Postnatal care

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will 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 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. Surgical benefits, not maternity benefits, apply to circumcision.

• We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits in Section 5(c) and Surgery benefits in Section 5(b).

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

In-network: No coinsurance for routine prenatal care or the first postpartum care visit when services are rendered by an in-network delivering health care provider.

For postpartum care visits thereafter:

In-network: 20% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: No coinsurance for routine prenatal care or the first postpartum care visit when services are rendered by an in-network delivering health care provider.

For postpartum care visits thereafter:

In-network: 0% of our Plan allowance

Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: Nothing at a network provider.

In-network: 0% of our Plan allowance

A range of voluntary family planning services limited to:

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

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

In-network: Nothing for women

For men:

In-network: 20% of our Plan allowance

In-network: Nothing for women

For men:

In-network: 20% of our Plan allowance

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

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

• Testing for diagnosis and surgical treatment of the underlying medical cause of infertility.

In-network: 20% of our Plan allowance

In-network: 20% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Any assisted reproductive technology (ART) procedure or services related to such procedures, including but not limited to in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and intra-cytoplasmic sperm injection (ICSI) or
• Artificial insemination (AI) and monitoring of ovulation:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI) or
• Any charges associated with care required to obtain Artificial insemination or ART services(e.g. office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for any Artificial insemination or ART procedures.
• Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services
• Services and supplies related to the above mentioned services, including sperm processing
• 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 sterilization surgery.
• Treatment for infertility when the cause of the infertility was a previous sterilization with or without surgical reversal
• Injectable fertility drugs, including but not limited to menotropins, hCG, GnRH agonists, and IVIG
• 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

• Testing and treatment
• Allergy injection
• Allergy serum*

In-network: 20% of our Plan allowance

Nothing for serum*

In-network: 0% of our Plan allowance

Nothing for serum*

Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.

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 on page 121.

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

Note: We cover growth hormone injectables under the prescription drug benefit.

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

Note:  Applied Behavior Analysis (ABA) – Children with autism spectrum disorder is covered under mental health. (See Section 5(e) for benefits)

In-network: 20% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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.

In-network: 0% of our Plan allowance

Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.

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.

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

  • Qualified Physical therapists
  • Occupational therapists

Note: We only cover therapy when a physician:

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

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

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

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

In-network: 20% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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.

In-network: 0% of our Plan allowance

Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.

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

Not covered:

• Long-term rehabilitative therapy

• 20 visits per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability.
• Cardiac rehabilitation following angioplasty, cardiovascular surgery, congestive heart failure or a myocardial infarction is provided for up to 3 visits a week for a total of 18 visits.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Habilitative services for 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 ability to function. Services include occupational therapy, physical therapy and speech therapy.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.

• 60 visits per person, per calendar year.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

• Routine hearing exam covered once every 24 months

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

In-network: Nothing

In-network: Nothing

All charges above $3,000.

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

All charges above $3,000.

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

Not covered:

• All other hearing testing and services that are not shown as covered
• Hearing aids charges over $3,000 every three (3) years, testing and examinations for them

• Treatment of eye diseases and injury

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Not Covered:

• Corrective eyeglasses and frames or contact lenses
• 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

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Not covered:

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

• Orthopedic devices such as braces and corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome and prosthetic devices such as artificial limbs and eyes
• 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. See Surgical Section 5(b) for coverage of the surgery to insert the device.
• Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

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

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

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

Note: Plan lifetime maximum of $500.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Not covered:

• Orthopedic and corrective shoes not attached to a covered brace
• Arch supports
• Foot orthotics
• Heel pads and heel cups
• Lumbosacral supports
• All charges over $500 for hair prosthesis

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Contact Plan at 888-238-6240 for specific covered DME. Some covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds (Clinitron and electric beds must be preauthorized)
• Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
• Crutches
• Walkers
• Insulin pumps and related supplies such as needles and catheters
• Certain bathroom equipment such as bathtub seats, benches and lifts

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Not covered:

• 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
• Elastic stockings and support hose

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

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

In-network: 20% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: 0% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

Acupuncture - when provided as anesthesia for covered surgery

Note: See page 128 for our coverage of acupuncture when provided as anesthesia for covered surgery.

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

In-network: 20% of our Plan allowance

In-network: 20% of our Plan allowance

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

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

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

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

Coverage is provided for:

• Tobacco cessation Programs, including individual/group/phone counseling, and for physician prescribed 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.

In-network: 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.

Out-of-network: Nothing up to our Plan allowance for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year. Nothing up to our Plan allowance for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.

In-network: 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.

Out-of-network: Nothing up to our Plan allowance for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year. Nothing up to our Plan allowance for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery) – a condition in which an individual has a body mass index (BMI) exceeding 40 or a BMI greater than 35 in conjunction with documented significant co-morbid conditions (such as coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea, nonalcoholic steatohepatitis (NASH) or refractory hypertension).
  • Members must have attempted weight loss in the past without successful long-term weight reduction; and Members must have participated in and been compliant with an intensive multicomponent behavioral intervention through a combination of dietary changes and increased physical activity for 12 or more sessions occurring within 2 years prior to surgery. Blood glucose control must be optimized, and psychological clearance may be necessary.

We will consider:

• Open or laparoscopic Roux-en-Y gastric bypass; or
• Open or laparoscopic biliopancreatic diversion with or without duodenal switch; or
• Sleeve gastrectomy; or
• Laparoscopic adjustable silicone gastric banding (Lap- Band) procedures.
• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information

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

• Voluntary sterilization for men (e.g., vasectomy)
• Treatment of burns
• Skin grafting and tissue implants
• Gender reassignment surgery*
  • The Plan will provide coverage for the following when the member meets Plan criteria:
    • Surgical removal of breasts for female-to-male patients
    • Surgical removal of uterus and ovaries in female-to-male and testes in male-to-female
    • Reconstruction of external genitalia**

* Subject to medical necessity
** Note: Requires Precertification.  See “Services requiring our prior approval” on pages 25-27. 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 888-238-6240.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

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

Nothing (no deductible)

Nothing (no deductible)

Not covered:

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

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

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

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form and for which the disfigurement is not associated with functional impairment, except repair of accidental injury

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

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

Note: When requesting oral and maxillofacial services, please check our online provider directory or call Member Services at 888-238-6240 for a participating oral and maxillofacial surgeon.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Not covered:

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

These solid organ transplants are subject to medical necessity and experimental / investigational review by the Plan. See Other services under You need prior Plan approval for certain services on pages 25-27.

• 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)

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

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

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

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Blood or marrow stem cell transplants

Physicians measure many features of leukemia or lymphoma cells to gain insight into its aggressiveness or likelihood of response to various therapies. Some of these include the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells can grow. These analyses may allow physicians to determine which diseases will respond to chemotherapy or which ones will not respond to chemotherapy and may rather 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 neuroblastoma
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)*
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow Failure and Related Disorders (i.e. Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast cancer*
  • Ependymoblastoma
  • Epithelial ovarian cancer*
  • Ewing's sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

*Approved clinical trial necessary for coverage.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• 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
• Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia)
• Myelodysplasia/Myelodysplastic Syndromes
• Paroxysmal Nocturnal Hemoglobinuria
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• 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
  • Neuroblastoma

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

These blood or marrow stem cell transplants covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols.

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
• Mini-transplants (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 (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

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

• *Note: Transplants must be performed at hospitals designated as Institutes of Excellence (IOE).  Hospitals in our network, but not designated as IOE hospitals will be covered at the out-of-network benefit level.

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

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Clinical trials must meet the following criteria:

A. The member has a current diagnosis that will most likely cause death within one (1) 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 (2) 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.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Not covered:

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

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

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

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Room and board, such as

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

In-network: 20% of our Plan allowance

In-network: 0% of our 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, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance

Not covered:

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

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

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

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

Note: In-network preventive care services are not subject to coinsurance listed.

In-network: 20% of our Plan allowance

In-network: 0% of our Plan allowance