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

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

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

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

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

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

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

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

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

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

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

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

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status including your marriage, divorce, annulment or when your child reaches age 26.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2022 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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

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

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

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

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices.  You can also visit OPM's website at: www.opm.gov/healthcare-insurance/healthcare/plan-information/. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

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

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

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

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 888-238-6240 or visit our website at www.aetnafeds.com.

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

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

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 888-238-6240 or write to us at Aetna, P.O. Box 14079, Lexington, KY 40512-4079. You may also request replacement cards through our Aetna Member website at www.aetnafeds.com.

You can get care from any licensed provider or licensed facility. How much we pay – and you pay – depends on whether you use a network or non-network provider or facility. If you use a non-network provider, you will pay more.

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

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

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

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

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

You can access care from any licensed provider or facility. Providers and facilities not in Aetna’s networks are considered non-network providers and facilities.

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

It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance.

Specialty care: If you have a chronic or disabling condition and lose access to your network specialist because we:

• Terminate our contract with your specialist for other than cause; or
• Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Program plan; or
• Reduce our service area and you enroll in another FEHB plan,

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

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

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

Note: Non-network physicians generally will make these arrangements too, but you are responsible for any precertification requirements.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services department immediately at 888-238-6240. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

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

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

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

In most cases, your Network physician or hospital will take care of precertification. Because you are still responsible for ensuring that we are asked to precertify your care, you should always ask your physician or hospital whether they have contacted us.

Some services require prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. We call this review and approval process precertification.

When you see a Plan physician, that physician must obtain approval for certain services such as inpatient hospitalization and the following services. If you see a non-participating physician you must obtain approval.

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

*For complete list refer to:

www.aetna.com/health-care-professionals/precertification/precertification-lists.html or the Behavioral Health Precertification list. The specialty medication precertification list can be found at: www.aetnafeds.com/pharmacy.php. You or your physician must obtain an approval for certain durable medical equipment (DME) including but not limited to electric or motorized wheelchairs and electric scooters. Members must call Member Services at 888-238-6240 for authorization

First, your physician, your hospital, you, or your representative, must call us at 888-238-6240 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

If the admission is a non-urgent admission or if you are being admitted to a Non-network hospital, you must get the days certified by calling the number shown on your ID card. This must be done at least 14 days before the date the person is scheduled to be confined as a full-time inpatient. If the admission is an emergency or an urgent admission, you, the person’s physician, or the hospital must get the days certified by calling the number shown on your ID card. This must be done:

• Before the start of a confinement as a full-time inpatient which requires an urgent admission; or
• Not later than one (1) business day following the start of a confinement as a full-time inpatient which requires an emergency admission; unless it is not possible for the physician to request certification within that time. In that case, it must be done as soon as reasonably possible. In the event the confinement starts on a Friday or Saturday, the 48 hour requirement will be extended to 72 hours.

If, in the opinion of the person’s physician, it is necessary for the person to be confined for a longer time than already certified, you, the physician, or the hospital may request that more days be certified by calling the number shown on your ID card. This must be done no later than on the last day that has already been certified.

Written notice of the number of days certified will be sent promptly to the hospital. A copy will be sent to you and to the physician.

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 888-238-6240. You may also call OPM's FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 888-238-6240. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

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

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

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

• If no one contacts us, we will decide whether the hospital stay was medically necessary.
  • If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.
  • If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.
• If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.
• When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:
  • for the part of the admission that was medically necessary, we will pay inpatient benefits, but
  • for the part of the admission that was not precertified or not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits

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

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

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

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

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

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial.

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

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

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

A copay is the fixed amount of money you pay when you receive certain services.  Example:  You pay a copayment of $10 to the pharmacy when you receive generic drugs on our formulary list.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them.

Aetna Advantage Plan

You must satisfy your deductible before your Traditional medical coverage begins. Note: Preventive services, are not subject to the annual deductible.  Your annual deductible is $2,000 for a Self Only enrollment, $4,000 for a Self Plus One enrollment and $4,000 for Self and Family enrollment in-network and $5,000 for a Self Only enrollment, $10,000 for a Self Plus One, and $10,000 for a Self and Family enrollment out-of-network.  Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

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

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

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

Example: You pay 30% of our Plan allowance for in-network durable medical equipment.

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

Non-Network Providers: If you use a non-network provider, you will have to pay the difference between our Plan allowance and the billed amount.

By using health care providers in Aetna’s network, you can take advantage of the significant discounts we have negotiated to help lower your out-of-pocket costs for medically necessary care. This can help you get the care you need at a lower price.

The example below is based on the following Aetna health benefits and insurance plan features and assumes you’ve already met your deductible:

What your plan pays (plan coinsurance):  70% in-network/50% out-of-network

What you pay (coinsurance): 30% in-network/50% out-of-network

Your out-of-pocket maximum: $7,500/$15,000 in-network; $10,000/$20,000 out-of-network***

Example: A five-day hospital stay- comparison of member costs in network versus out-of-network (see additional examples on our website: www.aetnafeds.com)

Hospital Bill - Amount Billed
In-network: $25,000
Out-of-network: $25,000

Amount Aetna uses to calculate payment - in-network rate (Doctors, hospitals and other health care providers in Aetna’s network accept Aetna’s payment rate and agree that you owe only your deductible and coinsurance)
In-network: $8,750
Out-of-network: N/A

Amount Aetna uses to calculate payment - Recognized amount out-of-network (When you go out of network, Aetna determines a recognized amount. You may be responsible for the difference between the billed amount and the recognized amount. In these examples, we have assumed that the recognized amount and the negotiated rate are the same amount. Actual amounts will vary.)
In-network: N/A
Out-of-network: $8,750

What your Aetna plan will pay - Negotiated /recognized amount
In-network: $8,750
Out-of-network: $8,750

What your Aetna plan will pay - Percent your plan pays
In-network: 70%
Out-of-network: 50%

What your Aetna plan will pay - Aetna’s negotiated rate/recognized amount covered under plan
In-network: $6,125
Out-of-network: $4,375

What you owe - Your coinsurance responsibility (In-network 30%, Out-of-network 50%)
In-network: $2,625
Out-of-network: $4,375

What you owe - Amount that can be balance billed to you
In-network: $0
Out-of-network: $16,250

What you owe - Your total responsibility
In-network: $2,625
Out-of-network: $20,625

*Doctors, hospitals and other health care providers in Aetna’s network accept Aetna’s payment rate and agree that you owe only your deductible and coinsurance.

**When you go out of network, Aetna determines a recognized amount. You may be responsible for the difference between the billed amount and the recognized amount. In these examples, we have assumed that the recognized amount and the negotiated rate are the same amount. Actual amounts will vary.
***Your plan caps out-of-pocket costs for covered services. The deductible and coinsurance you owe count toward that cap. But when you go out of network, the difference between the health care provider’s bill and the recognized amount does not count toward that cap.

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

Out-of-pocket maximums are the amount of out-of-pocket expenses that a Self Only, Self Plus One or a Self and Family will have to pay in a plan year. Out-of-pocket maximums apply on a calendar year basis only. Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical expenses at 100%. The remaining balance of the Self Plus One or Self and Family out-of-pocket maximum can be satisfied by one or more family members. Be sure to keep accurate records and receipts of your copayments, applicable deductible and coinsurance to ensure the Plan's calculation of your out-of-pocket maximum is reflected accurately.  In-network and Out-of-network out-of-pocket maximums do not cross apply and will need to be met separately in order for eligible medical expenses to be paid at 100%.

Aetna Advantage Plan

Only the deductible and those out-of-pocket expenses resulting from the application of coinsurance percentage (except any penalty amounts) and copayments may be used to satisfy the out-of-pocket maximums.

Note:  For the Aetna Advantage option, once you have met your deductible and satisfied your out-of-pocket maximums, eligible medical expenses will be covered at 100%.

If you have met your deductible, the following would apply:

Self Only:

In-network:  Your annual out-of-pocket maximum is $7,500.

Out-of-network:  Your annual out-of-pocket maximum is $10,000.

Self Plus One:

In-network: Your annual out-of-pocket maximum is $15,000.

Out-of-network: Your annual out-of-pocket maximum is $20,000.

Self and Family:

In-network:  Your annual out-of-pocket maximum is $15,000.

Out-of-network: Your annual out-of-pocket maximum is $20,000.

The following cannot be included in the accumulation of out-of-pocket expenses:

• Any expenses paid by the Plan under your In-network Preventive Care benefit
• Expenses in excess of our Plan allowance or maximum benefit limitations or expenses not covered under the Traditional medical coverage
• Any coinsurance expenses you have paid for infertility services 
• The $500 penalty for failure to obtain precertification when using a Non-network facility and any other amounts you pay because benefits have been reduced for non-compliance with this Plan’s cost containment requirements

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

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

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

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

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.

Please note: there are certain circumstances under the law where a provider can give you notice that they are out of network and you can consent to receiving a balance bill.  For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.aetnafeds.com or contact the health plan at 888-238-6240.

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

Deductible

$2,000 (Self Only)/$4,000(Self Plus One or Self and Family)

Coinsurance (medical)

30% of the Plan allowance

Catastrophic Maximum

$7,500 (Self Only)/$15,000 (Self Plus One or Self and Family)

Professional visit (PCP/Specialist)

30% of Plan allowance

Telehealth

$49 until the deductible is met, 30% of the $49 consult fee thereafter.

Preventive care (adult/child)

$0

Surgical care

30% of Plan allowance

Inpatient hospital

30% of Plan allowance

Outpatient

30% of Plan allowance

Emergency Room/Urgent Care

30% of Plan allowance

Pharmacy Tier 1 (30-day supply)

$10

Pharmacy Tier 2 (30-day supply)

45%

Part B premium reduction*

Reduced Medicare Part B premium by $100 per month

Deductible

$0

Coinsurance (medical)

0% of the Plan allowance

Professional visit (PCP/Specialist)

0% of Plan allowance

Preventive care (adult/child)

$0

Surgical care

0% of Plan allowance

Inpatient hospital

0% of Plan allowance

Outpatient

0% of Plan allowance

Emergency Room/Urgent Care

0% of Plan allowance

Pharmacy Tier 1 (30-day supply)

$2

Pharmacy Tier 2 (30-day supply)

$10

Pharmacy Tier 3 (30-day supply)

$40

Pharmacy Tier 4 (30-day supply)

$75

Pharmacy Tier 5 (30-day supply)

25% up to $350

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

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

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

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 50% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (Section 5). 

•  Routine mammogram - covered
• 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 50% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (Section 5). 

• Routine exam:
  • The following exams limited to:
    • One (1) routine eye exam every 12 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 50% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (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.   
• 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 
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder
• 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 50% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (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.

All charges

You must satisfy your deductible before your Traditional medical coverage begins.

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: $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment and $4,000 for Self and Family enrollment or

Out-of-Network: $5,000 per Self Only enrollment, $10,000 for Self Plus One enrollment or $10,000 per Self and Family enrollment.

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: 30% of our Plan allowance

Out-of-network: 50% 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 consults only).

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

In-network: $49 until the deductible is met, 30% of the $49 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: See Section 5(c) for cost sharing for these services not performed in a doctor's office.

*Note: CT Scans and MRIs require precertification see Section 3 "Services requiring our prior approval".

In-network: 30% of our Plan allowance

Out-of-network: 50% 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 Section 3 "Services requiring our prior approval". 

In-network: Nothing at a network provider

Out-of-network: 50% 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
• 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.
• See Hospital benefits (Section 5c) for member cost sharing (deductible and coinsurance) for in-network inpatient maternity care and Surgery benefits (Section 5b).

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

In-network: No cost share (no deductible) for routine prenatal care or the first postpartum care visit when services are rendered by an in-network delivering health care provider, 30% of our Plan allowance for postpartum care visits thereafter.

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: Nothing at a network provider (no deductible)

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

A range of voluntary family planning services limited to:

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

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

In-network: Nothing

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

Voluntary sterilization (See Surgical Procedures (Section 5b)

In-network: Nothing for women
For men:

In-network: 30% of our Plan allowance
Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing counseling

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

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

* Subject to medical necessity

** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240.

In-network: 30% of our Plan allowance

Out-of-network: 50% 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)
• Ovulation induction cycle(s) while on injectable medication to stimulate the ovaries
• Any charges associated with care required to obtain Artificial insemination or ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for any Artificial insemination or ART procedures except as stated above
• Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services
• Services associated with cryopreservation or storage of cryopreserved eggs and embryos (e.g. office, hospital, ultrasounds, laboratory tests etc.)
• Services and supplies related to the above mentioned services, including sperm processing
• 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
• Elective fertility preservation, such as egg freezing sought due to natural aging
• Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention
• Storage costs

• Testing and treatment
• Allergy injections
• Allergy serum

In-network: 30% of our Plan allowance

Out-of-network: 50% 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 Section 5(b). 

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

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

Note: We will only cover GHT when we preauthorize the treatment. Call 888-238-6240 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))

In-network: 30% of our Plan allowance 

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

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 three (3) visits a week for a total of 18 visits.

In-network: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

• 60 visits per person, per calendar year.

In-network: 30% of our Plan allowance

Out-of-network: 50% 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 (1) hearing exam every 24 months for adults
• 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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: Nothing

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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
• Medical foods taken for the treatment of Inborn Errors of Metabolism when provided by a participating DME provider and administered under the direction of a physician

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

In-network: 30% of our Plan allowance

Out-of-network: 50% 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
• Medical foods that do not require a prescription under Federal law even if your physician or other health care professional prescribes them 
• Nutritional supplements that are not administered by catheter or nasogastric tubes, except for oral medical foods taken for the treatment of Inborn Errors of Metabolism when administered under the direction of a physician

• Home health services ordered by 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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

In-network: 30% of our Plan allowance

Out-of-network: 50% 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

No benefit

All charges

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

In-network: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and

any difference between our allowance and the billed amount.

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 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 2 years prior to surgery. Blood glucose control must be optimized, and psychological clearance may be necessary.

We will consider:

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

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

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

• Voluntary sterilization for men (e.g.,vasectomy)
• Treatment of burns
• Skin grafting and tissue implants
• Gender affirming surgery* **
  • The Plan will provide coverage for the following when the member meets Plan criteria:
    • Must be 18 years of age
    • Surgical removal of breasts for female-to-male patients
    • Breast augmentation (implants/lipofilling) in male-to-female patients
    • Surgical removal of uterus and ovaries in female-to-male and testes in male-to-female
    • Reconstruction of external genitalia**

* Subject to medical necessity based on our clinical policy bulletin.
** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240.

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

In-network: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

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

Nothing (no deductible)

Not covered:

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

• 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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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 Section 3 Other services under You need prior Plan approval for certain services.

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

In-network: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

Blood or marrow stem cell transplants

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

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for:
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Acute myeloid leukemia
• Advanced Hodgkin's lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)*
• 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
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
  • Waldenstrom’s macroglobulinemia

*Approved clinical trial necessary for coverage.

In-network: 30% of our Plan allowance

Out-of-network: 50% 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. 

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

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP) 
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Non-myeloablative allogeneic, reduced intensity conditioning or RIC for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Myelodysplasia/Myelodysplastic Syndromes
  • Multiple sclerosis
  • 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
  • Advance 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
  • Scleroderma
  • Scleroderma-SSc (severe, progressive)
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

In-network: 30% of our Plan allowance

Out-of-network: 50% 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 an IOE hospital 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. 

Note

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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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.

Note: Inpatient hospice services require prior approval.

In-network: 30% of our Plan allowance

Out-of-network: 50% 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: 30% of our Plan allowance

Out-of-network: 50% 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 (Emergency Room), including doctors' services

In-network: 30% of our Plan allowance

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount.

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

In-network: $0 per visit

Out-of-network: 50% 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: $49 until the deductible is met, 30% of the $49 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: 30% of our Plan allowance

Out-of-network: 30% 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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

• Telemedicine Behavioral Health consult

In-network: 30% 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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

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 Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care.  You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240.

In-network: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our 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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our 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: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our 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
• Electro-convulsive therapy (ECT)
• Transcranial magnetic stimulation (TMS)
• Psychological/Neuropsychological testing

In-network: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our 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)
• Drugs to treat gender dysphoria

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

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

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

$10 per preferred generic (PG) formulary drug; and

45% per preferred brand (PB) formulary drug.

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

$20 per preferred generic (PG) formulary drug; and

45% per preferred brand (PB) formulary drug.

Out-of-network (retail pharmacies only):

50% 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 injectable contraceptives on our formulary list - five (5) vials per calendar year
• Generic emergency contraception, including over-the-counter (OTC) when filled with a prescription
• Diaphragms - one (1) per calendar year
• Brand name Intra Uterine Device
• Generic patch contraception

Note: If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at www.aetnafeds.com/pharmacy.php to review our 2023 Pharmacy Drug (Formulary) Guide or call 800-537-9384.

In-network: Nothing (no deductible)

Out-of-network (retail pharmacies only):

50% 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

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:

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

45% per preferred brand (PB) formulary drug.

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

45% per preferred brand (PB) formulary drug.

Out-of-network (retail pharmacies only):

50% 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 above, Specialty Drugs for more information or visit:  www.aetnafeds.com/pharmacy.php

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

$10 per preferred generic (PG) formulary drug; and

45% per preferred brand (PB) formulary drug.

Limited benefits:

• Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period.

In-network:

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

$10 per preferred generic (PG) formulary drug; and

45% per preferred brand (PB) formulary drug.

Out-of-network (retail pharmacies only):

50% 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 some over-the-counter, when prescribed by a health care professional and filled at a network pharmacy.

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

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

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

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

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

In-network:  Nothing (no deductible)

Not covered:

• Drugs for cosmetic purposes, such as Rogaine
• Drugs to enhance athletic performance
• Nonprescription medications unless specifically indicated elsewhere
• 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 not listed as a covered benefit, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition unless otherwise stated
• Prophylactic drugs including, but no 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 Section 5(a)).  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.

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

We have no other dental benefits.

In-network: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

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

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

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

You can:

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

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

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

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

To obtain claim forms or other claims filing advice or answers about your benefits, contact us at 888-238-6240.

In most cases, providers and facilities file claims for you. Your Provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 888-238-6240, or at our website at www.aetnafeds.com.

When you must file a claim, such as when you use non-network providers, for services you receive overseas or when another group health plan is primary, submit it on the Aetna claim form. You can obtain this form by either calling us at 888-238-6240 or by logging onto your personalized home page on Aetna Member website from the www.aetnafeds.com website and clicking on “Forms.” Bills and receipts should be itemized and show:

• Name of patient and relationship to enrollee
• Covered member's name, date of birth, address, phone number and ID number
• Name, address and taxpayer identification number of person or firm providing the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply

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

In addition:

• You must send a copy of the explanation of benefits (EOB) payments or denial from any primary payor - such as Medicare Summary Notice (MSN) with your claim
• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse
• Claims for rental or purchase of durable medical equipment; private duty nursing; and physical, occupational, and speech therapy require a written statement from the physician specifying the medical necessity for the service or supply and the length of time needed
• Claims for prescription drugs and supplies that are not obtained from a network pharmacy or through the Mail Order Service Prescription Drug Program must include receipts that include the prescription number, name of drug or supply, prescribing physician’s name, date and charge
• You should provide an English translation and currency conversion rate at the time of services for claims for overseas (foreign) services

Send us all of the documents for your claim as soon as possible:

Aetna Life Insurance Company
P.O. Box 14079
Lexington, KY 40512-4079

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

For covered services you receive in hospitals outside the United States and performed by physicians outside the United States, send a completed Claim Form and the itemized bills to the following address. Also send any written inquiries, concerning the processing of overseas claims to:

Aetna Life Insurance Company
P.O. Box 14079
Lexington, KY 40512-4079

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

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

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

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

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

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

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

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

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

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

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

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

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

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

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

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We do not cover services that:

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

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

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

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

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

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

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

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

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

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

This Plan always pays secondary to:

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

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

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

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

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost

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

1. The Workers’ Compensation benefits are in dispute or are paid by means of settlement or compromise;
2. No final determination is made that bodily injury or sickness was sustained in the course of or resulted from the member’s employment;
3. The amount of Workers’ Compensation benefits due to medical or health care is not agreed upon or defined by the member or the OWCP or other Workers’ Compensation carrier; or
4. The medical or health care benefits are specifically excluded from the Workers’ Compensation settlement or compromise.

By accepting benefits under this Plan, the member or the member’s representatives agree to notify Aetna of any Workers’ Compensation claim made, and to reimburse us as described above. Aetna may exercise its recovery rights against the provider in the event:

1. the employer or carrier is found liable or responsible according to a final adjudication of the claim by the OWCP or other party responsible for adjudicating such claims; or
2. an order approving a settlement agreement is entered; or
3. the provider has previously been paid by the carrier directly, resulting in a duplicate payment

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

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s cancer, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan. See Section 5(b).
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs. See Section 5(b).
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs. See Section 5(b).

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

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

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be authorized or precertified as required. Also, please note that if your attending physician does not participate in Medicare, you will have to file a claim with Medicare.

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 888-238-6240.

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

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

Aetna Advantage: (See Medicare Advantage Plan (Part C) below for the Aetna Medicare Advantage Plan option if you are enrolled in Medicare Parts A and B)

Benefit Description: Deductible
You pay without Medicare: $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment, $4,000 for Self and Family enrollment in-network
You pay with Medicare Parts A and B (primary): $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment, $4,000 for Self and Family enrollment in-network

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

Benefit Description: Primary Care Physician
You pay without Medicare: 30% of Plan allowance
You pay with Medicare Parts A and B (primary): 30% of Plan allowance

Benefit Description: Specialist
You pay without Medicare: 30% of Plan allowance
You pay with Medicare Parts A and B (primary): 30% of Plan allowance

Benefit Description: Inpatient Hospital
You pay without Medicare: 30% of Plan allowance
You pay with Medicare Parts A and B (primary): 30% of Plan allowance

Benefit Description: Outpatient Hospital
You pay without Medicare: 30% of Plan allowance
You pay with Medicare Parts A and B (primary): 30% of Plan allowance

Benefit Description: Incentives offered
You pay without Medicare: N/A
You pay with Medicare Parts A and B (primary): See below for how we coordinate if you opt into Aetna Medicare Advantage Part D plan.

You can find more information about how our plan coordinates benefits with Medicare by calling 888-238-6240 or visit our website at www.aetnafeds.com.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (800-633-4227), (TTY:877-486-2048) 24 hours a day/7 days a week or at www.medicare.gov.

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

This Plan and our Aetna Medicare Advantage plan: You may enroll in our national Medicare Advantage Plan if you are an annuitant or former spouse with FEHBP coverage and are enrolled in Medicare Parts A and B. Our Medicare Advantage plan will enhance your FEHB coverage by lowering/eliminating cost-sharing for services and/or adding benefits at no additional cost. Aetna Medicare Advantage plan is subject to Medicare rules. You can enroll in our Medicare Advantage plan with no additional premium. If you are already enrolled and would like to understand your additional benefits in more detail, please refer to your Medicare plan’s Evidence of Coverage. If you are enrolling in our Aetna Medicare Advantage plan, please call us at 866-241-0262 or go to www.aetnaretireehealth.com/fehbp.

Note: To receive the benefits outlined in the chart below for Aetna Medicare Advantage, you do not suspend your FEHB coverage. 

By choosing this plan, retired enrollees age 65 and over with Medicare as primary coverage, agree that you have or will have Medicare Parts A and B by your effective date. You agree that you will be enrolled in our Aetna Medicare Advantage Plan. We may need more information to enroll you in this plan prior to your effective date. If this is not completed, your benefits will be significantly impacted, i.e. $2,000 deductible not waived and you will pay 30% coinsurance on most services.

This 2023 benefit summary allows you to make a side-by-side comparison:

Medical Benefit: Part B Premium Reduction
Aetna Advantage Plan (without Medicare): No reimbursement
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):$100 per month

Medical Benefit: Deductible
Aetna Advantage Plan (without Medicare):$2,000 (Self Only)/$4,000(Self Plus One or Self and Family)
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):$0

Medical Benefit: Coinsurance (medical)
Aetna Advantage Plan (without Medicare):30% of the Plan allowance
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):0% of the Plan allowance

Medical Benefit: Catastrophic Maximum
Aetna Advantage Plan (without Medicare):$7,500 (Self Only)/$15,000(Self Plus One or Self and Family)
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):N/A

Medical Benefit: Professional visit (PCP/Specialist)
Aetna Advantage Plan (without Medicare):30% of the Plan allowance
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):0% of the Plan allowance

Medical Benefit: Telehealth
Aetna Advantage Plan (without Medicare):$49 until the deductible is met, 30% of the $49 consult fee thereafter.
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):0% of the Plan allowance

Medical Benefit: Preventive care (adult/child)
Aetna Advantage Plan (without Medicare):$0
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):$0

Medical Benefit: Surgical care
Aetna Advantage Plan (without Medicare):30% of Plan allowance
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):0% of Plan allowance

Medical Benefit: Inpatient hospital
Aetna Advantage Plan (without Medicare):30% of Plan allowance
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):0% of Plan allowance

Medical Benefit: Outpatient
Aetna Advantage Plan (without Medicare):30% of Plan allowance
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):0% of Plan allowance

Medical Benefit: Emergency Room/Urgent Care
Aetna Advantage Plan (without Medicare):30% of Plan allowance
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):0% of Plan allowance

Medical Benefit: Pharmacy Tier 1 (30-day supply)
Aetna Advantage Plan (without Medicare):$10
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):$2

Medical Benefit: Pharmacy Tier 2 (30-day supply)
Aetna Advantage Plan (without Medicare):45%
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):$10

Medical Benefit: Pharmacy Tier 3 (30-day supply)
Aetna Advantage Plan (without Medicare):N/A
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):$40

Medical Benefit: Pharmacy Tier 4 (30-day supply)
Aetna Advantage Plan (without Medicare):N/A
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):$75

Medical Benefit: Pharmacy Tier 5 (30-day supply)
Aetna Advantage Plan (without Medicare):N/A
Aetna Medicare Advantage Plan (with Medicare Parts A&B primary):25% up to $350

Additional Programs that come with our Aetna Medicare Advantage Plan:

Part B Premium Reduction

We will reduce the Part B premium that you pay to the Social Security Administration by $100 per month. If you pay your Part B premium on a monthly basis, you will see this dollar amount credited in your Social Security check. If you pay your Part B premium quarterly, you will see an amount equaling three months of reductions credited on your quarterly Part B premium statement. It may take a few months to see these reductions credited to either your Social Security check or premium statement, but you will be reimbursed for any credits you did not receive during this waiting period.

SilverSneakers^®

An overall wellness program that may help members improve their health and live the life they want. The program gives members access to exercise equipment, classes, and fun social activities at thousands of locations nationwide. 

Hearing aid reimbursement

Reimbursement is $2,500/every 36 months 

Resources For Living

Aetna signature program which helps you find the resources you need in your daily lives. With just one call, a life consultant can help you find local resources to make life easier and treat your entire health, including your social and mental well-being. 

Non-emergency transportation program

A program that ensures you make it to and from your doctor or hospital appointments without always having to rely on family or friends. 

Important Information about your enrollment in our Aetna Medicare Advantage plan

Aetna Medicare Advantage Plan (PPO with ESA) is a Medicare contract separate from the FEHB Aetna Advantage Plan and depends on contract renewal with CMS.

Aetna Medicare is a PPO plan with a Medicare contract. You may also see an additional charge if you qualify for the Income-Related Monthly Adjustment Amount (IRMAA). It is an extra amount that you pay for your monthly Medicare Part D prescription drug plan premiums and your monthly Medicare Part B premiums. Social Security makes this determination based on your income. Enrollment in our plans depends on contract renewal. See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

For a copy of your Evidence of Coverage go to www.aetnafeds.com/Advantage.

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

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

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. For more information, please call us at 800-832-2640. See Important Notice from Aetna about our Prescription Drug Coverage and Medicare on the first inside page of this brochure for information on Medicare Part D.

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

When you use network providers, your annual maximum for out-of-pocket expenses, deductibles, coinsurance, and copayments) for covered services is limited to the following:

Aetna Advantage Plan

Self Only:

In-network:  Your annual out-of-pocket maximum is $7,500.

Out-of-network: Your annual out-of-pocket maximum is $10,000.

Self Plus One:

In-network: Your annual out-of-pocket maximum is $15,000.

Out-of-network: Your annual out-of-pocket maximum is $20,000.

Self and Family:

In-network:  Your annual out-of-pocket maximum is $15,000.

Out-of-network: Your annual out-of-pocket maximum is $20,000.

However, certain expenses under both options do not count towards your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum. Refer to Section 4.  In-network and Out-of-network out-of-pocket maximums do not cross apply and will need to be met separately in order for eligible medical expenses to be paid at 100%.

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

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

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s cancer, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this plan.  See Section 5(b).
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs.  See Section 5(b). 
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials.  This Plan does not cover these costs.  See Section 5(b).

See Section 4.

See Section 4.

See Section 4.

Care we provide benefits for, as described in this brochure.

Any type of care provided according to Medicare guidelines, including room and board, that a) does not require the skills of technical or professional personnel; b) is not furnished by or under the supervision of such personnel or does not otherwise meet the requirements of post-hospital Skilled Nursing Facility care; or c) is a level such that you have reached the maximum level of physical or mental function and such person is not likely to make further significant improvement. Custodial care includes any type of care where the primary purpose is to attend to your daily living activities which do not entail or require the continuing attention of trained medical or paramedical personnel. Examples include assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, changes of dressings of noninfected wounds, post-operative or chronic conditions, preparation of special diets, supervision of medication which can be self-administered by you, the general maintenance care of colostomy or ileostomy, routine services to maintain other service which, in our sole determination, is based on medically accepted standards, can be safely and adequately self-administered or performed by the average non-medical person without the direct supervision of trained medical or paramedical personnel, regardless of who actually provides the service, residential care and adult day care, protective and supportive care including educational services, rest cures, or convalescent care. Custodial care that lasts 90 days or more is sometimes known as long term care. Custodial care is not covered.

See Section 4.

The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate regulatory authority, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient at a minimum.

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

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

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

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

Also known as medically necessary or medically necessary services.  “Medically necessary" means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is:

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

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

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

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Network provider plans determine their allowances in different ways. We determine our allowance as follows:

• Network Providers - we negotiate rates with doctors, dentists and other health care providers to help save you money. We refer to these providers as “Network Providers". These negotiated rates are our Plan allowance for network providers.  We calculate a member’s coinsurance using these negotiated rates.  The member is not responsible for amounts that are billed by network providers that are greater than our Plan allowance.
• Non-Network Providers - Providers that do not participate in our networks are considered non-network providers. Because they are out of our network, we pay for out-of-network services based on an out-of-network Plan allowance.  Here is how we figure out the Plan allowance/recognized charge.

The amount of an out-of-network provider's charge that is eligible for coverage.  You are responsible for all amounts above what is eligible for coverage.

The recognized charge depends on the geographic area where you receive the service or supply.  The information below shows the method for calculating the recognized charge for specific services or supplies:

Service or Supply: Professional services and other services or supplies not mentioned below

Plan Allowance/Recognized Charge: 105% of the Medicare allowable rate

Service or Supply: Services of hospitals and other facilities

Plan Allowance/Recognized Charge: 140% of the Medicare allowable rate

Important note: If the provider bills less than the amount calculated using the method above, the recognized charge is what the provider bills.

Special terms used

• Geographic area is normally based on the first three digits of the U.S. Postal Service zip codes. If we determine we need more data for a particular service or supply, we may base rates on a wider geographic area such as an entire state. 
• Involuntary services are services or supplies that are one of the following:
  • Performed at a network facility by an out-of-network provider, unless that out-of-network provider is an assistant surgeon for your surgery
  • Not available from a network provider
  • Emergency services

We will calculate your cost share for involuntary services in the same way as we would if you received the services from a network provider.

• Medicare allowed rates are the rates CMS establishes for services and supplies provided to Medicare enrollees. We update our systems with these revised rates within 180 days of receiving them from CMS. If Medicare does not have a rate, we use one or more of the items below to determine the rate:
  • The method CMS uses to set Medicare rates
  • What other providers charge or accept as payment
  • How much work it takes to perform a service
  • Other things as needed to decide what rate is reasonable for a particular service or supply
• We may make the following exceptions:
  • For inpatient services, our rate may exclude amounts CMS allows for Operating Indirect Medical Education (IME) and Direct Graduate Medical Education (DGME).
  • Our rate may also exclude other payments that CMS may make directly to hospitals or other providers. It also may exclude any backdated adjustments made by CMS.
  • For anesthesia, our rate is 105% of the rates CMS establishes for those services or supplies.
  • For laboratory, our rate is 75% of the rates CMS establishes for those services or supplies.
  • For DME, our rate is 75% of the rates CMS establishes for those services or supplies.
  • For medications payable/covered as medical benefits rather than prescription drug benefits, our rate is 100% of the rates CMS establishes for those medications.

Our reimbursement policies

We reserve the right to apply our reimbursement policies to all out-of-network services including involuntary services. Our reimbursement policies may affect the recognized charge. These policies consider:

• The duration and complexity of a service
• When multiple procedures are billed at the same time, whether additional overhead is required
• Whether an assistant surgeon is necessary for the service
• If follow-up care is included
• Whether other characteristics modify or make a particular service unique
• When a charge includes more than one claim line, whether any services described by a claim line are part of or related to the primary service provided
• The educational level, licensure or length of training of the provider

Our reimbursement policies are based on our review of:

• The Centers for Medicare and Medicaid Services’ (CMS) National Correct Coding Initiative (NCCI) and other external materials that say what billing and coding practices are and are not appropriate
• Generally accepted standards of medical and dental practice
• The views of physicians and dentists practicing in the relevant clinical areas

We use commercial software to administer some of these policies. The policies may be different for professional services and facility services. 

We use the Plan allowance/Recognized charge when calculating a member’s coinsurance amount.  The member would be responsible for any amounts billed by the non-network provider that are above this Plan allowance/recognized charge, plus their coinsurance amount.

Note:  See Section 4 of this brochure and www.aetnafeds.com for examples of member cost sharing for procedures in and out-of-network.

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

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

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

A carrier's pursuit of a recovery if a covered individual that has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Care furnished during a period of time when your family or usual caretaker cannot, or will not, attend to your needs. Respite care is not covered.

Covered benefits required in order to prevent serious deterioration of your health that results from an unforeseen illness or injury if you are temporarily absent from our service area and receipt of the health care service cannot be delayed until your return to our service area.

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department at 888-238-6240.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us and we refer to Aetna Life Insurance Company.

You refers to the enrollee and each covered family member.

Nothing

39

In-network: 30% of our Plan allowance
Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount

44

In-network: $49 until the deductible is met, 30% of the $49 consult fee thereafter.
Out-of-network: No benefit. Must use Teladoc provider.

45

In-network: 30% of our Plan allowance
Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

65

In-network: 30% of our Plan allowance
Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

65

In-network: 30% of our Plan allowance

Out-of-network:  30% of our Plan allowance and any difference between our allowance and the billed amount.

69

In-network: 30% of our Plan allowance

Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

71

74

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

$10 per covered preferred generic formulary drug; and 45% per covered preferred brand formulary drug.

Out-of-network (retail pharmacies only): (Out-of-network deductible applies) 50% plus the difference between our Plan allowance and the billed amount.

76

Preferred: $10 per covered preferred generic formulary drug; and 45% per covered preferred brand formulary drug.

78

For a 31-day up to a 90-day supply per prescription or refill:

$20 per covered preferred generic formulary drug; and

45% per covered preferred brand formulary drug.

76

No benefit

80

Nothing

50

Contact Plan

81

In-network:  Nothing after $7,500/Self Only enrollment, $15,000/Self Plus One enrollment, or $15,000/Self and Family enrollment per year.

Out-of-network: Nothing after $10,000/Self Only enrollment, $20,000/Self Plus One enrollment, or $20,000/Self and Family enrollment per year.

Some costs do not count toward this protection. Your deductible counts toward your out-of-pocket maximum.

31