Serving the following states: Arizona, California, Georgia, Indiana, New Jersey, New York, Ohio, Pennsylvania, Tennessee, and Washington.
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See pages 9 -11 for requirements as well as for NCQA
accreditations.
Enrollment code for Phoenix & Tucson AZ: Enrollment code for New York, NY: WQ1 Self Only JC1 Self Only
WQ2 Self and Family JC2 Self and Family Enrollment code for Southern CA: Enrollment code for Cleveland, OH:
2X1 Self Only 7D1 Self Only 2X2 Self and Family 7D2 Self and Family
Enrollment code for Atlanta & Athens GA: Enrollment code for Memphis, TN: 2U1 Self Only UB1 Self Only
2U2 Self and Family UB2 Self and Family Enrollmen7t code for Southeastern IN & Cincinnati, OH Enrollment code for Nashville & Middle TN:
RD1 Self Only 6J1 Self Only RD2 Self and Family 6J2 Self and Family
Enrollment code for NJ & Southeastern PA: Enrollment code for Western & Southeast WA: P31 Self Only 8J1 Self Only
P32 Self and Family 8J2 Self and Family
Special Notice 1. Members in Enrollment Code RD (Northern KY area); Enrollment Code 7D (Toledo, OH area only); and Enrollment Code 2X (San Diego county, CA only): We reduced a portion of our Service Areas for the above
Enrollment Codes. You must select another FEHB plan during Open Season if you live or work in the affected counties of these Enrollment Codes. If you do not select another FEHB plan during Open Season, you will be covered only for
emergency care in 2003.
Special Notice 2. Members in Enrollment Code 7L (Southern IN and Louisville, KY); Enrollment Code TG (Binghamton and Syracuse, NY); and Enrollment Code 8L (Southern NV and Las Vegas area): We eliminated the
above Enrollment areas. You must select another FEHB plan during Open Season if you currently are enrolled in these Codes. If you do not select another FEHB plan during Open Season, you will have no benefits in 2003.
For changes in benefits
see page 12.
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3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.
Sincerely,
Kay Coles James Director
2.
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4
Notes
3.
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5
Notice of the Office of Personnel Management's Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give
you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
.. To you or someone who has the legal right to act for you (your personal representative),
.. To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected, .. To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
.. Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
.. To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf
asks for our assistance regarding a benefit or customer service issue. .. To review, make a decision, or litigate your disputed claim.
.. For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
.. For Government healthcare oversight activities (such as fraud and abuse investigations),
.. For research studies that meet all privacy law requirements (such as for medical research or education), and
.. To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at
any time, except if OPM has already acted based on your permission.
By law, you have the right to:
.. See and get a copy of your personal medical information held by OPM.
.. Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
4.
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Page 5
6
.. Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will
not cover your personal medical information that was given to you or your personal representative, any information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay
for your health care or a disputed claim. .. Ask OPM to communicate with you in a different manner or at a different place (for example, by sending
materials to a P. O. Box instead of your home address). .. Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be
able to agree to your request if the information is used to conduct operations in the manner described above. .. Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60
days of the change. The privacy practices listed in this notice will be effective April 14, 2003.
5.
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7
2003 Aetna Health 2 Table of Contents
Table of Contents
Introduction ................................................................................................................................................................... 4
Plain Language .............................................................................................................................................................. 4
Stop Health Care Fraud! ................................................................................................................................................ 5
Section 1. Facts about this HMO plan....................................................................................................................... 6
How we pay providers ............................................................................................................................. 6
Your Rights .............................................................................................................................................. 7
Service Area............................................................................................................................................. 9
Section 2. How we change for 2003 ....................................................................................................................... 12
Program-wide changes ........................................................................................................................... 12
Changes to this Plan ............................................................................................................................... 12
Section 3. How you get care ................................................................................................................................... 14
Identification cards................................................................................................................................. 14
Where you get covered care ................................................................................................................... 14
.. Plan providers.............................................................................................................................. 14
.. Plan facilities ............................................................................................................................... 14
What you must do to get covered care ................................................................................................... 14
.. Primary care ................................................................................................................................ 14
.. Specialty care .............................................................................................................................. 14
.. Hospital care................................................................................................................................ 16
Circumstances beyond our control ......................................................................................................... 16
Services requiring our prior approval..................................................................................................... 16
Section 4. Your costs for covered services.............................................................................................................. 18
.. Copayments ................................................................................................................................. 18
.. Deductible ................................................................................................................................... 18
.. Coinsurance ................................................................................................................................. 18
Your catastrophic protection out-of-pocket maximum .......................................................................... 18
Section 5. Benefits .................................................................................................................................................. 19
Overview................................................................................................................................................ 19
(a) Medical services and supplies provided by physicians and other health care professionals .................................................................................................... 20
(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................................................................................... 29
(c) Services provided by a hospital or other facility, and ambulance services.................................. 33
(d) Emergency services/ accidents ..................................................................................................... 36
(e) Mental health and substance abuse benefits ................................................................................ 39
(f) Prescription drug benefits............................................................................................................ 41
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8
2003 Aetna Health 3 Table of Contents
(g) Special features............................................................................................................................ 44 .. Services for the deaf and hearing impaired....................................................................... 44
.. Informed Health . Line ..................................................................................................... 44
.. Maternity Management Program TM .................................................................................. 44
.. National Medical Excellence Program . ........................................................................... 44
.. Reciprocity benefit............................................................................................................ 44
(h) Dental benefits............................................................................................................................. 45
(i) Non-FEHB benefits available to Plan members .......................................................................... 48
Section 6. General exclusions things we don't cover......................................................................................... 49
Section 7. Filing a claim for covered services......................................................................................................... 50
Section 8. The disputed claims process................................................................................................................... 51
Section 9. Coordinating benefits with other coverage............................................................................................. 53
When you have other health coverage ................................................................................................... 53
.. What is Medicare......................................................................................................................... 53
.. Medicare managed care plan ....................................................................................................... 56
.. TRICARE and CHAMPVA ........................................................................................................ 56
.. Workers' Compensation .............................................................................................................. 57
.. Medicaid...................................................................................................................................... 57
.. Other Government agencies ........................................................................................................ 57
.. When others are responsible for injuries ..................................................................................... 57
Section 10. Definitions of terms we use in this brochure.......................................................................................... 59
Section 11. FEHB facts ............................................................................................................................................. 61
Coverage information............................................................................................................................. 61
.. No pre-existing condition limitation............................................................................................ 61
.. Where you get information about enrolling in the FEHB Program............................................. 61
.. Types of coverage available for you and your family ................................................................. 61
.. Children's Equity Act.................................................................................................................. 62
.. When benefits and premiums start .............................................................................................. 62
.. When you retire ........................................................................................................................... 62
When you lose benefits .......................................................................................................................... 63
.. When FEHB coverage ends......................................................................................................... 63
.. Spouse equity coverage ............................................................................................................... 63
.. Temporary Continuation of Coverage (TCC).............................................................................. 63
.. Converting to individual coverage .............................................................................................. 63
.. Getting a Certificate of Group Health Plan Coverage ................................................................. 64
Long Term Care Insurance is still available ................................................................................................................ 65
Index............................................................................................................................................................................ 66
Summary of benefits.................................................................................................................................................... 67
Rates ............................................................................................................................................................................ 69
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2003 Aetna Health 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits you can receive of Aetna Health Inc.* under our contract (CS 2867) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for
Aetna's administrative office is:
Aetna Health Inc. 930 Harvest Drive
Mail Stop U33N Blue Bell, PA 19422
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that
were available before January 1, 2003, unless these benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 12. Rates are shown at the end of this brochure.
Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,
.. Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family
member; "we" means Aetna Health.
.. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office
of Personnel Management. If we use others, we tell you what they mean first.
.. Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or email OPM at fehbwebcomments@ opm. gov. You may also write
to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW, Washington, DC 20415-3650.
*HMO benefits are provided or administered by:
Legal Entity Carrier Code
Aetna Health Inc. (AZ) WQ Aetna Health of California Inc. 2X
Aetna Health Inc. (GA) 2U Aetna Health Inc. (NJ) P3 (NJ)
Aetna Health Inc. (NY) JC Aetna Health Inc. (OH) RD/ 7D
Aetna Health Inc. (PA) P3 (PA) Aetna Health Inc. (TN) 6J/ UB
Aetna Health Inc. (WA) 8J
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2003 Aetna Health 5 Introduction/ Plain Language/ Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
.. Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to
your doctor, other provider, or authorized plan or OPM representative.
.. Let only the appropriate medical professionals review your medical record or recommend services.
.. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill
us to get it paid.
.. Carefully review explanations of benefits (EOBs) that you receive from us.
.. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or
service.
.. If you suspect that a provider has charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:
.. Call the provider and ask for an explanation. There may be an error.
.. If the provider does not resolve the matter, call us at 1-800/ 537-9384 and explain the situation.
.. If we do not resolve the issue:
.. Do not maintain as a family member on your policy:
.. Your former spouse after a divorce decree or annulment is final (even if a court order stipulates
otherwise); or
.. Your child over age 22 (unless he/ she is disabled and incapable of self support).
.. If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed
or with OPM if you are retired.
.. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB
benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.
CALL THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415.
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2003 Aetna Health 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection
of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of
treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other
provider will be available and/ or remain under contract with us.
How we pay providers .. Provider Compensation We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your
copayments or coinsurance.
This is a direct contract prepayment Plan, which means that participating providers are neither agents nor employees of the Plan.
Rather, they are independent doctors and providers who practice in their own offices or facilities. The Plan arranges with licensed providers and
hospitals to provide medical services for both the prevention of disease and the treatment of illness and injury for benefits covered under the
Plan.
Plan providers in our network have agreed to be compensated in various ways. Many participating primary care physicians (PCPs) are paid by
capitation. Under capitation, a physician receives payment for a patient whether the physician sees the patient that month or not.
Specialists, hospitals, primary care physicians and other providers in the Aetna Health Inc. network may also be paid in the following ways:
.. Per individual service (fee-for-service at contracted rates),
.. Per hospital day (per diem contracted rates),
.. Under other capitation methods (a certain amount per member, per
month), and
.. By Integrated Delivery Systems (" IDS"), Independent Practice
Associations (" IPAs"), Physician Medical Groups (" PMGs"), Physician Hospital Organizations (" PHOs"), behavioral health
organizations and similar provider organizations or groups that are paid by Aetna Health; the organization or group pays the physician
or facility directly. In such arrangements, that group or organization has a financial incentive to control the costs of providing care.
You are encouraged to ask your physicians and other providers how they are compensated for their services, including whether their
specific arrangements include any financial incentives to control costs.
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2003 Aetna Health 7 Section 1
Your Rights OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
Medical Necessity Covered services include most types of treatment by PCPs, specialists and hospitals. However, the health plan also excludes or
limits coverage for some services including, but not limited to, cosmetic surgery and experimental procedures. In addition, in order to be covered, all services, including the location (type of facility), duration and costs of services, must be medically
necessary as defined in this Plan and as determined by us. (See definition on Page 60.)
Direct Access Ob/ Gyn Program This program allows female members to visit any participating gynecologist for a routine well-woman exam, including a Pap
smear (if appropriate) and an unlimited number of visits for gynecologic problems and follow-up care as described in your benefits plan. Gynecologists may also refer a woman directly for covered gynecologic services without the patient having to go
back to her participating primary care physician. If your Ob/ Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG) or a similar organization, covered care must be coordinated through the IPA, the PMG or the
similar organization.
Mental Health/ Substance Abuse In most areas, certain behavioral health care services (e. g., treatment or care for mental disease or illness, alcohol abuse and/ or
substance abuse) are managed by an independently contracted organization. This organization makes initial coverage determinations and coordinates referrals; any behavioral health care referrals will generally be made to providers affiliated with
the organization, unless your needs for covered services extend beyond the capability of the affiliated providers. You can receive information regarding the appropriate way to access the behavioral health care services that are covered under your specific plan
by calling Member Services at 1-800/ 537-9384. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the provisions of your Plan.
Ongoing Reviews We conduct ongoing reviews of those services and supplies which are recommended or provided by health
professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such
determination, you may then contact us to seek a review of the determination.
Authorization Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits
under this Plan.
Patient Management We have developed a patient management program to assist in determining what health care services are covered under the
health plan and the extent of such coverage. The program assists members in receiving the appropriate health care and maximizing coverage for those health care services.
Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial letters delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal process.
Our patient management staff uses national guidelines and resources to guide the precertification, concurrent review and retrospective review processes. Using the information obtained from providers, patient management staff utilizes Milliman &
Robertson Care Guidelines (M& R Care Guidelines . ) when conducting concurrent reviews. If there is no applicable M& R Care Guideline, patient management staff utilizes InterQual ISD criteria. When applicable, Medicare National Coverage Decisions are
followed for Medicare managed care members. To the extent certain patient management functions are delegated to integrated delivery systems, independent practice associations or other provider groups (" Delegates"), such Delegates utilize criteria that
they deem appropriate.
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2003 Aetna Health 8 Section 1
.. Precertification Certain health care services, such as hospitalization or outpatient
surgery, require precertification by us to ensure coverage. When a member is to obtain services requiring precertification through a Plan
provider, this provider should precertify those services prior to treatment.
.. Concurrent Review The concurrent review process assesses the necessity for continued stay,
level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification
period will require Concurrent Review.
.. Discharge Planning Discharge planning may be initiated at any stage of the patient
management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The
discharge plan may include initiation of a variety of services/ benefits to be utilized by the member upon discharge from an inpatient stay.
.. Retrospective Record
Review The purpose of retrospective record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of
inpatient concurrent review decisions for coverage and payment of health care services. Our effort to manage the services provided to
members includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and
utilization concerns.
Member Services Representatives from Member Services are trained to answer your questions and to assist you in using the Aetna Health plan
properly and efficiently. After you receive your ID card, you can call the Member Services toll-free number on the card when you need to:
.. Ask questions about benefits and coverage.
.. Notify us of changes in your name, address or telephone number.
.. Change your primary care physician or office.
.. Obtain information about how to file a grievance or an appeal.
Confidentiality We protect the privacy of confidential Plan member medical information. We contractually require that participating providers
keep member information confidential in accordance with applicable laws. Furthermore, you have the right to access your medical records from participating providers, at any time. Aetna Health Inc., including its affiliates and authorized agents,
collectively (" Aetna Health") and participating providers require access to member medical information for a number of important and appropriate purposes, including claims payment, fraud prevention, coordination of care, data collection,
performance measurement, fulfilling state and federal requirements, quality management, utilization review, research and accreditation activities, preventive health, and early detection and disease management programs. Accordingly, for these
purposes, members authorize the sharing of member medical information about themselves and their dependents between Aetna Health Inc. and Plan providers and health delivery systems.
Protecting the privacy of member health information is a top priority at Aetna. When contacting us about this FEHB Program brochure or for help with other questions, please be prepared to provide your or your family member's name, member ID (or
Social Security Number), and date of birth.
If you want more information about us, call 1-800/ 537-9384, or write to 930 Harvest Drive, Mail Stop U33N, Blue Bell, PA 19422. You may also contact us by fax at 215/ 775-5246 or visit our website at www. aetna. com/ custom/ fehbp.
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2003 Aetna Health 9 Section 1
Service Area To enroll in this Plan, you must live or work in our service area. This is where our providers practice.
Our service area is:
Arizona
2/ 02 This service has
Excellent accreditation from the NCQA.
See the 2003 Guide for more information on accreditation.
Serving: Phoenix and Tucson areas
Enrollment Code:
WQ1 Self Only WQ2 Self and Family
Cochise, Maricopa, Pima and Santa Cruz counties and portions of Pinal as defined by the towns of Apache Junction and Casa Grande
California
5/ 00 This service has Commendable
accreditation from the NCQA. See the 2003 Guide for more
information on accreditation.
Serving: Southern California area
Enrollment Code:
2X1 Self Only 2X2 Self and Family
Los Angeles, Orange, Santa Barbara and Ventura counties, and portions of Kern, Riverside, and San Bernardino counties as defined below:
Kern County: All towns except Cantil, China Lake, Garlock, Johannesburg, Mojave, and Ridgecrest
Riverside County: All towns except Blythe, Desert Center, Mesa Verde, and Ripley
San Bernardino County: All towns except Amboy, Baker, Big River, Cadiz, Cima, Danby, Earp, Essex, Ivonpah, Kelso, Lake Havasu, Needles, Nipton, Parker Dam,
Rice, and Vidal
Georgia
8/ 01 This service has Excellent
accreditation from the NCQA. See the 2003 Guide for more
information on accreditation.
Serving: The Atlanta and Athens areas
Enrollment Code:
2U1 Self Only 2U2 Self and Family
Barrow, Bartow, Butts, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Hall, Haralson, Heard,
Henry, Jackson, Lamar, Madison, Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Rockdale, Spalding and Walton counties
Indiana
4/ 02 This service has Excellent
accreditation from the NCQA. See the 2003 Guide for more
information on accreditation.
Serving: Southeastern Indiana area
Enrollment Code:
RD1 Self Only RD2 Self and Family
Dearborn, Franklin, Ohio and Switzerland counties
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2003 Aetna Health 10 Section 1
New Jersey
3/ 01 This service has Excellent
accreditation from the NCQA. See the 2003 Guide for more
information on accreditation.
Serving: All of New Jersey
Enrollment Code:
P31 Self Only P32 Self and Family
The State of New Jersey
New York
5/ 01 This service has Excellent
accreditation from the NCQA. See the 2003 Guide for more
information on accreditation.
Serving: New York City area
Enrollment Code:
JC1 Self Only JC2 Self and Family
Bronx, Dutchess, Kings (Brooklyn), Nassau, New York (Manhattan), Orange, Putnam, Queens, Richmond (Staten Island), Rockland, Suffolk, Sullivan, Ulster
and Westchester counties
Ohio
4/ 02 This service has Excellent
accreditation from the NCQA. See the 2003 Guide for more
information on accreditation.
Serving: Greater Cincinnati area
Enrollment Code:
RD1 Self Only RD2 Self and Family
Adams, Brown, Butler, Champaign, Clark, Clermont, Clinton, Greene, Hamilton, Highland, Logan, Miami, Montgomery, Preble, Shelby and Warren counties
Serving: Cleveland area
Enrollment Code:
7D1 Self Only 7D2 Self and Family
Ashland, Ashtabula, Carroll, Cuyahoga, Geauga, Holmes, Lake, Lorain, Mahoning, Medina, Portage, Richland, Stark, Summit, Trumbull, Tuscarawas and
Wayne counties and portions of the following county as defined by the below listed towns:
Columbiana: Beloit, Columbiana, East Palestine, East Rochester, Elkton, Hanoverton, Homeworth, Kensington, Leetonia, Lisbon, Minerva, Negley,
New Waterford, North Georgetown, Rogers, Salem, Salineville, Washingtonville, West Point and Winona
Pennsylvania
12/ 99 This service has Excellent
accreditation from the NCQA. See the 2003 Guide for more
information on accreditation.
Serving: Philadelphia and Southeastern Pennsylvania
Enrollment Code:
P31 Self Only P32 Self and Family
Berks, Bucks, Chester, Delaware, Lehigh, Monroe, Montgomery and Northampton counties, and Philadelphia
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2003 Aetna Health 11 Section 1
Tennessee
3/ 01 This service has Excellent
accreditation from the NCQA. See the 2003 Guide for more
information on accreditation.
Serving: The Memphis area
Enrollment Code:
UB1 Self Only UB2 Self and Family
Crockett, Dyer, Fayette, Haywood, Lauderdale, Shelby and Tipton counties
Serving: Nashville and Middle Tennessee areas
Enrollment Code:
6J1 Self Only 6J2 Self and Family
Bedford, Cannon, Cheatham, Coffee, Davidson, DeKalb, Dickson, Franklin, Giles, Hickman, Humphreys, Lawrence, Lewis, Lincoln, Macon, Marshall, Maury,
Moore, Perry, Robertson, Rutherford, Smith, Sumner, Trousdale, Wayne, Williamson and Wilson counties
Washington Serving: Western and Southeast Washington areas
Enrollment Code:
8J1 Self Only 8J2 Self and Family
King, Kitsap, Pierce and Snohomish counties
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services
have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or
an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.
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2003 Aetna Health 12 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes ..
A Notice of the Office of Personnel Management's Privacy Practices is included.
.. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family
coverage.
.. Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their
FEHB Program enrollment.
.. Program information on Medicare is revised.
.. By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan ..
Enrollment Code 2U. Your share of the non-Postal premium will increase by 24.7% for Self Only or increase by 18.3% for Self and Family.
.. Enrollment Code 2X. Your share of the non-Postal premium will increase by 12.5% for Self Only or increase by
14.3% for Self and Family.
.. Enrollment Code 6J. Your share of the non-Postal premium will decrease by 5.6% for Self Only or decrease by
36.4% for Self and Family.
.. Enrollment Code 7D. Your share of the non-Postal premium will decrease by 7.4% for Self Only or decrease by
22.1% for Self and Family.
.. Enrollment Code 8J. Your share of the non-Postal premium will increase by 13.7% for Self Only or increase by
11.2% for Self and Family.
.. Enrollment Code JC. Your share of the non-Postal premium will increase by 18.1% for Self Only or increase by
17.5% for Self and Family.
.. Enrollment Code P3. Your share of the non-Postal premium will decrease by 14.8% for Self Only or decrease by
27.8% for Self and Family.
.. Enrollment Code RD. Your share of the non-Postal premium will decrease by 19.7% for Self Only or decrease by
29.7% for Self and Family.
.. Enrollment Code UB. Your share of the non-Postal premium will increase by 24.3% for Self Only or increase by
3.1% for Self and Family.
.. Enrollment Code WQ. Your share of the non-Postal premium will increase by 1. 2% for Self Only or decrease by
1.2% for Self and Family.
.. We increased the inpatient hospital per admission copay to $250 per day up to a maximum of 3 days, or $750, for
both Medical and Mental Health/ Substance Abuse confinements. (Section 5( c))
.. We increased the copay to $200 for outpatient hospital for ambulatory surgical center care. (Section 5( c) )
.. We increased the copay to $100 per visit for emergency care in the outpatient department of a hospital or at an
urgent care center, both within and outside the service area. (Section 5( d))
.. We increased the copay to $25 per 30-day supply for brand name formulary prescription drugs. (Section 5( f))
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2003 Aetna Health 13 Section 2
.. We increased the copay to $50 per 31-day up to a 90-day supply for brand name formulary prescription drugs.
(Section 5( f))
.. We changed the copay to $40 per 30-day supply for non-formulary prescription drugs. (Section 5( f))
.. We changed the copay to $80 for a 31-day up to a 90-day supply of non-formulary prescription drugs. (Section
5( f))
.. We increased the copay to $25 per vial of Depo Provera. (Section 5( f))
.. We increased the copay to $25 for one Diaphragm per year. (Section 5( f))
.. We now exclude benefits for travel related drugs including, but not limited to, anti-malarial drugs. (Section 5( f))
.. We reduced a portion of our Service Area for 2003. If you are in Enrollment Code RD (Northern KY area) and live
or work in the following counties: Boone, Campbell, Gallatin, Grant, Kenton, and Pendleton, you must select another FEHB plan during Open Season. If you do not select another FEHB plan during Open Season, you will be
covered only for emergency care in 2003. (See cover and page 9)
.. We reduced a portion of our Service Area for 2003. If you are in Enrollment Code 7D (Toledo, OH area only), and
live or work in the following counties: Allen, Crawford, Erie, Hancock, Hardin, Henry, Lucas, Ottawa, Putnam, Sandusky, and Seneca, as well as portions of the counties of Auglaize, Fulton, Huron, and Wood, you must select
another FEHB plan during Open Season. If you do not select another FEHB plan during Open Season, you will be covered only for emergency care in 2003. (See cover and page 9)
.. We eliminated a portion of our Service Area for 2003. If you are in Enrollment Code 2X (Southern CA area) and
live or work in San Diego county, you must select another FEHB plan during Open Season. If you do not select another FEHB plan during Open Season, you will be covered only for emergency care in 2003. (See cover and
page 9)
.. We eliminated some enrollment areas for calendar year 2003. They are:
.. Enrollment Code 7L (Southern IN and Louisville, KY); for Southern IN, this includes Clark, Floyd, Harrison,
Scott, and Washington counties; and for Louisville, KY, this includes Bullitt, Hardin, Henry, Jefferson, Larue, Meade, Nelson, Oldham, Shelby, Spencer, and Trimble counties;
.. Enrollment Code TG (Binghamton and Syracuse, NY); this includes Broome, Cayuga, Onandaga, Oswego,
and Tioga counties; and
.. Enrollment Code 8L (Southern NV and Las Vegas area); this includes Clark county.
If you currently are enrolled in these Codes, you must select another FEHB plan during Open Season. If you do not select another FEHB plan during Open Season, you will have no benefits in 2003. (See cover and page 9)
With the above reductions in Service Areas, and the elimination of Enrollment Codes, we will no longer be offered in the States of Kentucky or Nevada. (See cover and page 9)
.. We terminated Contract CS 2836, brochure RI 73-778, at the end of calendar year 2002, and merged the following
Enrollment Codes under Contract CS 2836 into Contract CS 2867, brochure RI73-806, effective January 1, 2003: WQ (Phoenix and Tucson, AZ areas), 2X (Southern CA area), 2U (Atlanta and Athens, GA areas), P3 (All of NJ
and Southeastern PA), and 8J (Western and Southeast WA areas). If you currently are in one of these Enrollment Codes, your enrollment will be transferred automatically to Contract CS 2867, brochure RI 73-806, unless you
select another FEHB plan during Open Season. (See cover and page 9)
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2003 Aetna Health 14 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your 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
1-800/ 537-9384 or write to us at Aetna Health, 1425 Union Meeting Road, P. O. Box 1125, Blue Bell, PA 19422. You may also request
replacement cards through our website at www. aetna. com/ custom/ fehbp.
Where you get covered care You get covered care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file
claims.
.. Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The most current information on our Plan providers is also
on our website at www. aetna. com/ custom/ fehbp under DocFind.
To ensure covered services, you must notify Member Services at 1-800/ 537-9384 of your primary care physician selection.
.. Plan facilities Plan facilities are hospitals and other facilities in our service area that
we contract with to provide covered services to our members. We list these facilities in the provider directory, which we update periodically.
The most current information on our Plan facilities is also on our website at www. aetna. com/ custom/ fehbp.
What you must do to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for most of your health care. You must select a Plan provider who is located
in your service area as defined by your enrollment code.
.. Primary care Your primary care physician can be a general practitioner, family
practitioner, internist or pediatrician. Your primary care physician will provide or coordinate most of your health care, or give you a referral to
see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us or visit our website. We will change
your primary care physician to a newly-selected primary care physician.
.. Specialty care Your primary care physician will refer you to a specialist for needed
care. If you need laboratory, radiological and physical therapy services, your primary care physician must refer you to certain plan providers. If
you need mental health or substance abuse care, you may call your primary care physician or the behavioral health vendor number on the
front of your ID card. Your primary care physician may refer you to any participating specialist for other specialty care. When you receive a
referral from your primary care physician, you must return to the
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2003 Aetna Health 15 Section 3
primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional
referrals. The primary care physician must provide or authorize follow-up care. Do not go to the specialist for return visits unless your primary
care physician gives you a referral. However, you may see a Plan gynecologist, (within an IPA, you must see an IPA-approved
gynecologist), for a routine well-woman exam, including a pap smear (if appropriate) and an unlimited number of visits for gynecological
problems and follow-up care as described in your benefit plan without a referral. You may also see a Plan mental health provider, Plan vision
specialist or a Plan dentist without a referral.
Here are other things you should know about specialty care:
.. If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist
for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your
treatment plan (the physician may have to get an authorization or approval beforehand).
.. If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to
a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive
treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
.. If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another specialist. You may receive services from your current
specialist until we can make arrangements for you to see someone else.
.. If you have a chronic or disabling condition and lose access to your
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 Plan; or
.. Reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.
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2003 Aetna Health 16 Section 3
.. Hospital care Your Plan 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.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800/ 537-9384. If you
are new to the FEHB Program, we will arrange for you to receive care.
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;
or
.. 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.
Circumstances beyond our control 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.
Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain 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.
You must obtain approval for certain services such as:
.. For artificial insemination you must contact the Infertility Case
Manager at 1-800/ 575-5999;
.. You must obtain precertification from your primary care doctor and
Aetna Health for covered follow-up care with non-participating providers;
.. You must contact Customer Service at 1-800/ 537-9384 or call the
behavioral health contractor for information on precertification before you have mental health and substance abuse services.
Your Plan physician must obtain approval for certain services such as hospitalization and the following services:
.. For surgical treatment of morbid obesity;
.. For select outpatient surgery;
.. For inpatient confinements, skilled nursing facilities, rehabilitation
facilities, and inpatient hospice;
.. For covered transplant surgery;
.. When full-time skilled nursing care is necessary in an extended care
facility;
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2003 Aetna Health 17 Section 3
.. For non-emergent ambulance transportation service;
.. For certain drugs before they can be prescribed;
.. For growth hormone therapy treatment;
.. For penile implants;
.. For all home healthcare services; and
.. For certain outpatient imaging studies such as CT scans, MRIs, and
MRAs.
You or your physician must obtain an approval for certain durable medical equipment. Members must call 1-800/ 537-9384 for
authorization.
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23
2003 Aetna Health 18 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
.. Copayments A copayment is a fixed amount of money you pay to the provider,
facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $20 per office visit or $25 when you see a participating
specialist.
.. Deductible We do not have a deductible.
Note: If you change plans during open season, you do not have to start a new deductible under your old 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.
.. Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay
for your care.
Example: In our Plan, you pay 50% of our allowance for drugs to treat sexual dysfunction
Your catastrophic protection out-of-pocket maximum for
copayments and coinsurance
After your copayments and coinsurance total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to
pay any more for covered services. However, copayments and coinsurance for the following services do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:
.. Prescription drugs
.. Dental services
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the
maximum.
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24
2003 Aetna Health 19 Section 5
Section 5. Benefits OVERVIEW (See page 12 for how our benefits changed this year and page 67 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 1-800/ 537-9384 or at our website at www. aetna. com/ custom/ fehbp.
(a) Medical services and supplies provided by physicians and other health care professionals ................................ 20 .
Diagnostic and treatment services . Speech therapy .
Lab, X-ray, and other diagnostic tests . Hearing services (testing, treatment, and supplies) .
Preventive care, adult . Vision services (testing, treatment, and supplies) .
Preventive care, children . Foot care .
Maternity care . Orthopedic and prosthetic devices .
Family planning . Durable medical equipment (DME) .
Infertility services . Home health services .
Allergy care . Chiropractic .
Treatment therapies . Alternative treatments .
Physical, pulmonary and occupational therapies . Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health care professionals............................. 29 .
Surgical procedures . Organ/ tissue transplants .
Reconstructive surgery . Anesthesia .
Oral and maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services........................................................... 33 .
Inpatient hospital . Hospice care .
Outpatient hospital or ambulatory surgical center . Ambulance .
Extended care benefits/ skilled nursing care facility benefits
(d) Emergency services/ accidents .............................................................................................................................. 36 .
Medical emergency . Ambulance
(e) Mental health and substance abuse benefits ......................................................................................................... 39
(f) Prescription drug benefits..................................................................................................................................... 41
(g) Special features..................................................................................................................................................... 44 .
Services for deaf and hearing-impaired ............................................................................................................ 44 .
Informed Health Line........................................................................................................................................ 44 .
Maternity Management Program...................................................................................................................... 44 .
National Medical Excellence Program.............................................................................................................. 44
.. Reciprocity Benefit ........................................................................................................................................... 44
(h) Dental benefits...................................................................................................................................................... 45
(i) Non-FEHB benefits available to Plan members ................................................................................................... 48
Summary of benefits.................................................................................................................................................... 67
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2003 Aetna Health 20 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits: ..
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary. ..
Plan physicians must provide or arrange your covered care. ..
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians ..
In physician's office
Office medical consultations
Second surgical or medical opinion
Initial examination of a newborn child covered under a family enrollment
$20 per primary care physician (PCP) visit
$25 per specialist visit
Professional services of physicians ..
In an urgent care center for a routine service ..
During a hospital stay ..
In a skilled nursing facility
$20 per PCP visit $25 per specialist visit
At home $25 per PCP visit $30 per specialist visit
At home visits by nurses and health aides Nothing
Lab, X-ray and other diagnostic tests
Tests, such as: ..
Blood tests ..
Urinalysis ..
Non-routine pap tests ..
Pathology ..
X-rays ..
Non-routine Mammograms ..
CT Scans/ MRI ..
Ultrasound ..
Electrocardiogram and EEG
Nothing if you receive these services during
your office visit; otherwise, $20 per PCP
visit or $25 per specialist visit
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26
2003 Aetna Health 21 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
.. Total Blood Cholesterol
.. Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50
.. Routine Prostate Specific Antigen (PSA) test one annually for men
age 40 and older
.. Routine Pap test
NOTE: No copay for the pap test if performed on the same day as the office visit.
Routine mammogram covered for women age 35 and older, as follows: ..
From age 35 through 39, one during this five year period ..
From age 40 through 64, one every calendar year ..
At age 65 and older, one every two consecutive calendar years
$20 per PCP visit $25 per specialist visit
Nothing if provided during the office visit
Routine immunizations limited to: ..
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)
.. Influenza vaccine, annually
.. Pneumococcal vaccine, age 65 and over
Nothing if provided during the office visit
Not covered: ..
Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.
.. Immunizations and boosters for travel or work-related exposure.
All charges
Preventive care, children
.. Childhood immunizations recommended by the American Academy of
Pediatrics Nothing
.. Well-child visits for routine examinations, immunizations and care (up
to age 22) $20 per PCP visit $25 per specialist visit
.. Examinations, such as:
.. Eye exams through age 17 to determine the need for vision
correction
.. Ear exams through age 17 to determine the need for hearing
correction
.. Examinations done on the day of immunizations (up to age 22)
$20 per PCP visit $25 per specialist visit
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2003 Aetna Health 22 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as: ..
Prenatal care ..
Delivery ..
Postnatal care
NOTE: Here are some things to keep in mind:
.. You do not need to precertify your normal delivery; see below for
other circumstances, such as extended stays for you or your baby. ..
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended
inpatient stay if your Physician determines it is medically necessary. ..
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 and Family enrollment. Surgical benefits, not maternity
benefits, apply to circumcision. ..
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
$20 for the first PCP visit only or $25 for the first
specialist visit only
Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to: ..
Voluntary sterilization (See Surgical procedures Section 5( b)) ..
Surgically implanted contraceptives ..
Injectable contraceptive drugs (such as Depo Provera) ..
Intrauterine devices (IUDs) ..
Diaphragms
NOTE: We cover oral contraceptives and Depo Provera under the prescription drug benefit.
$20 per PCP visit $25 per specialist visit
Not covered: Reversal of voluntary surgical sterilization, genetic counseling All charges
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2003 Aetna Health 23 Section 5( a)
Infertility services You pay
Infertility is defined as the inability to conceive after 12 months of unprotected intravaginal sexual relations (or 12 cycles of artificial
insemination) for women under age 35 and 6 months of unprotected intravaginal sexual relations (or 6 cycles of artificial insemination) for
women age 35 and over.
Diagnosis and treatment of infertility, such as: ..
Artificial insemination:
.. intravaginal insemination (IVI)
.. intracervical insemination (ICI)
.. intrauterine insemination (IUI)
NOTE: Coverage is only for 6 cycles. Artificial insemination must be authorized. You must contact the Infertility Case Manager at
1-800/ 575-5999. You must use our select network of Plan infertility providers.
.. Fertility drugs except injectables
NOTE: We cover oral fertility drugs under the prescription drug benefit.
$25 per specialist visit
Not covered: ..
Reversal of voluntary, surgically-induced sterility.
.. Treatment for infertility when the cause of the infertility was a previous
sterilization.
.. Injectable fertility drugs
.. Infertility treatment when the FSH level is greater than 19 mIU/ ml.
.. The purchase, freezing and storage of donor sperm and donor
embryos.
.. Assisted reproductive technology (ART) procedures, such as:
.. In vitro fertilization
.. Embryo transfer including, but not limited to, gamete GIFT and
zygote ZIFT
All charges
Allergy care
Testing and treatment
Allergy injection
NOTE: You pay the applicable copay for each doctor visit. Each visit to a nurse for injection only, you pay nothing
$20 per PCP visit $25 per specialist visit
Nothing for a visit to a nurse
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges
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29
2003 Aetna Health 24 Section 5( a)
Treatment therapies You pay
.. Chemotherapy and radiation therapy
NOTE: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 31.
.. Respiratory and inhalation therapy
.. Dialysis hemodialysis and peritoneal dialysis
.. Intravenous (IV) Infusion Therapy Home IV and antibiotic therapy
.. Growth hormone therapy (GHT)
NOTE: Growth hormone is covered under Medical Benefits, office copay applies.
NOTE: We will only cover GHT when we preauthorize the treatment. Call 1-800/ 245-1206 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only
cover GHT services from the date you submit the information. 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.
$25 per specialist visit
Physical, pulmonary and occupational therapies
.. Two consecutive months per condition per member per calendar year,
beginning with the first day of treatment for the services of each of the following:
.. Qualified physical therapists
.. Occupational therapists
.. Pulmonary rehabilitation therapists
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 rehabilitation is covered under Hospital/ Extended Care Benefits.
.. Cardiac rehabilitation following angioplasty, cardiovascular surgery,
congestive heart failure or a myocardial infarction is provided for up to 3 visits a week for a total of 18 visits.
.. Physical therapy to treat temporomandibular joint (TMJ) dysfunction
syndrome
$25 per visit, Nothing during a covered
inpatient admission
Not covered: ..
Long-term rehabilitative therapy
All charges
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2003 Aetna Health 25 Section 5( a)
Speech therapy You pay
.. Two consecutive months per condition per member per calendar year,
beginning with the first day of treatment $25 per visit, Nothing during a covered inpatient admission
Hearing services (testing, treatment, and supplies)
.. Covered for audiological testing and medically necessary treatment for
hearing problems $20 per PCP visit $25 per specialist visit
Not covered: ..
Hearing aids, testing and examinations for them
All charges
Vision services (testing, treatment, and supplies)
.. Treatment of eye diseases and injury $20 per PCP visit
$25 per specialist visit
.. Corrective eyeglasses and frames or contact lenses (hard or soft)
per 24 month period. All charges over $100
.. Routine eye refraction based on the following schedule:
.. If member wears eyeglasses or contact lenses:
Age 1 through 18 once every 12-month period Age 19 and over once every 24-month period
.. If member does not wear eyeglasses or contact lenses:
To age 45 once every 36-month period ..
Age 45 and over once every 24-month period
NOTE: See Preventive Care, Children for eye exams for children
$25 per specialist visit
Not covered: ..
Fitting of contact lenses ..
Eye exercises ..
Radial keratotomy, including related procedures designed to surgically correct refractive errors
All charges
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31
2003 Aetna Health 26 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.
See Orthopedic and prosthetic devices for more information.
$20 per PCP visit $25 per specialist visit
Not covered: ..
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except
as stated above ..
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment
is by open manipulation or fixation) ..
Foot orthotics ..
Podiatric shoe inserts
All charges
Orthopedic and prosthetic devices
.. Orthopedic devices such as braces 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, penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract
removal. Note: See 5( b) for coverage of the surgery to insert the device.
.. Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
NOTE: Coverage includes repair and replacement when due to growth or normal wear and tear.
Nothing
Not covered: ..
Orthopedic and corrective shoes not attached to a covered brace ..
Arch supports ..
Foot orthotics ..
Heel pads and heel cups ..
Lumbosacral supports
All charges
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2003 Aetna Health 27 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, including replacement, repair and adjustment, of durable medical equipment prescribed by your Plan Physician such as
oxygen equipment. Under this benefit, we also cover: ..
Hospital beds; ..
Wheelchairs (motorized wheelchairs must be preauthorized); ..
Crutches; ..
Walkers; and ..
Insulin pumps.
NOTE: Some DME may require precertification by you or your physician.
Nothing
Not covered: ..
Elastic stockings and support hose ..
Bathroom equipment such as bathtub seats, benches, rails and lifts ..
Home modifications such as stairglides, elevators and wheelchair ramps
All charges
Home health services
.. Home health care ordered by a Plan Physician and provided by nurses
and home health aides. Your Plan Physician will periodically review the program for continuing appropriateness and need.
.. Services include intravenous therapy and medications.
Nothing
Not covered: ..
Nursing care requested by, or for the convenience of, the patient or the patient's family.
.. Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.
All charges
Chiropractic
Chiropractic services up to 20 visits per member per calendar year ..
Manipulation of the spine and extremities ..
Adjunctive procedures such as ultrasound, electric muscle stimulation, vibratory therapy and cold pack application
$25 per specialist visit
Not covered: Any services not listed above All charges
Alternative treatments
No benefits All charges
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2003 Aetna Health 28 Section 5( a)
Educational classes and programs You pay
.. Asthma
.. Diabetes
.. Congestive heart failure
.. Low back pain
.. Coronary artery disease
Also see the Non-FEHB page for our InteliHealth and Fitness Program.
Nothing
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34
2003 Aetna Health 29 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits: ..
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary. ..
Plan physicians must provide or arrange your care. ..
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare. ..
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c)
for charges associated with the facility (i. e., hospital, surgical center, etc.) ..
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification
information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
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 a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to
current underwriting standards; eligible members must be age 18 or over. This procedure must be approved in advance by the HMO.
.. Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information. ..
Voluntary sterilization (e. g., Tubal ligation, Vasectomy) ..
Treatment of burns
NOTE: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.
$20 per PCP office visit, $25 per specialist visit
33.
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2003 Aetna Health 30 Section 5( b)
Surgical procedures (continued) You pay
Not covered: .. Reversal of voluntary surgically-induced sterilization
.. Surgery primarily for cosmetic purposes
.. Radial keratotomy, including related procedures designed to
surgically correct refractive errors ..
Whole blood and concentrated red blood cells not replaced by the member
All charges
Reconstructive surgery
.. Surgery to correct a functional defect
.. Surgery to correct a condition caused by injury or illness if:
.. The condition produced a major effect on the member's appearance
and ..
The condition can reasonably be expected to be corrected by such surgery
.. Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes. ..
All stages of breast reconstruction surgery following a mastectomy, such as:
.. Surgery to produce a symmetrical appearance on the other breast;
.. Treatment of any physical complications, such as lymphedemas;
.. Breast prostheses and surgical bras and replacements (see
Prosthetic devices)
NOTE: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
$25 per specialist visit
Not covered: ..
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury ..
Surgeries related to sex transformation
All charges
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36
2003 Aetna Health 31 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, such as: ..
Treatment of fractures of the jaws or facial bones; ..
Surgical correction of congenital defects, such as cleft lip and cleft palate; ..
Medically necessary surgical treatment of TMJ; ..
Removal of stones from salivary ducts; ..
Excision of leukoplakia or malignancies; ..
Removal of bony impacted wisdom teeth; ..
Excision of tumors and cysts ..
Other surgical procedures that do not involve the teeth or their supporting structures.
$25 per specialist visit
Not covered: ..
Dental implants ..
Dental care involved with the treatment of temporomandibular joint dysfunction
All charges
Organ/ tissue transplants
Limited to: ..
Cornea ..
Heart ..
Heart/ lung ..
Kidney ..
Liver ..
Lung: Single Double ..
Pancreas ..
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach and
pancreas ..
Skin ..
Tissue ..
Allogeneic (donor) bone marrow/ peripheral stem cell transplants ..
Autologous bone marrow/ peripheral stem cell transplants (autologous stem cell and peripheral stem cell support) for the following conditions:
acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell
tumors
$25 per specialist office visit and nothing for the surgery
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2003 Aetna Health 32 Section 5( b)
Organ/ tissue transplants (continued) You pay
.. Autologous tandem transplants for testicular tumors
.. National Transplant Program (NTP) Transplants which are non-experimental
or non-investigational are a covered benefit. Covered transplants must be ordered by your primary care doctor and plan
specialist physician and approved by our medical director in advance of the surgery. The transplant must be performed at hospitals
(Institutes of Excellence) specifically approved and designated by us to perform these procedures. A transplant is non-experimental and
non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as
appropriate treatment for your specific condition. Coverage for a transplant where you are the recipient includes coverage for the
medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.
Limited Benefits Treatment for breast cancer, multiple myeloma and epithelial ovarian cancer may be provided in a National Cancer Institute
(NCI)-or National Institute of Health (NIH)-approved clinical trial at a Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols.
NOTE: Harvesting of tissue for storage purposes only is not eligible for coverage. If both the donor and the transplant recipient are covered by us,
donor expenses are attributed to the transplant recipient's coverage. Aetna does not extend coverage for donor services when the transplant
recipient is not our member.
$25 per specialist office visit and nothing for the
surgery
Not covered: ..
Transplants not listed as covered
All charges
Anesthesia
Professional services provided in ..
Hospital (inpatient) ..
Hospital outpatient department ..
Skilled nursing facility ..
Ambulatory surgical center ..
Office
NOTE: When the anesthesiologist is the primary giver of services, such as for pain management, the specialist copay applies.
Nothing
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38
2003 Aetna Health 33 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits: ..
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary. ..
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
.. Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
.. The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i. e., physicians, etc.) are
covered in Sections 5( a) or (b). ..
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services
require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board, such as ..
Ward, semiprivate, or intensive care accommodations; ..
General nursing care; and ..
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.
$250 per day up to a maximum of $750 per
admission
Other hospital services and supplies, such as: ..
Operating, recovery, maternity, and other treatment rooms ..
Prescribed drugs and medicines ..
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
Nothing
Inpatient hospital Continued on the next page
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39
2003 Aetna Health 34 Section 5( c)
Inpatient hospital (Continued) You pay
Not covered: ..
Whole blood and concentrated red blood cells not replaced by the member
.. Custodial care, rest cures, domiciliary or convalescent cares
.. Personal comfort items, such as telephone and television
All charges
Outpatient hospital or ambulatory surgical center
.. Operating, recovery, and other treatment rooms
.. Prescribed drugs and medicines
.. 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
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.
$200 per visit
Services not associated with a medical procedure being done the same day, such as:
.. Mammogram
.. Radiologic procedures
.. Lab tests
$25 per specialist visit
Not covered: Whole blood and concentrated red blood cells not replaced by the member. All charges
Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 90-day limit per calendar year when full-time
nursing care is necessary and the confinement is medically appropriate as determined by a Plan doctor and approved by the Plan.
Nothing
Not covered: custodial care All charges
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40
2003 Aetna Health 35 Section 5( c)
Hospice care You pay
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 a Plan doctor, who certifies the patient is in the terminal stages of illness, with a life
expectancy of approximately 6 months or less.
Nothing
Ambulance
.. Ambulance service ordered or authorized by a Plan doctor Nothing
Not covered: Ambulance services for routine transportation to receive outpatient or inpatient services. All charges
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41
2003 Aetna Health 36 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits: ..
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary. ..
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency? A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious;
examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There
are many other acute conditions that we may determine are medical emergencies what they all have in common is the need for quick action.
What to do in case of emergency:
If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a
prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a
pregnant woman, the health of the woman and her unborn child.
Whether you are in or out of an Aetna Health HMO service area, we simply ask that you follow the guidelines below when you believe you need emergency care.
.. Call the local emergency hotline (e. g., 911) or go to the nearest emergency facility. If a delay would not be
detrimental to your health, call your primary care provider. Notify your primary care provider as soon as possible after receiving treatment.
.. After assessing and stabilizing your condition, the emergency facility should contact your primary care
physician so they can assist the treating physician by supplying information about your medical history. ..
If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify your primary care physician or us as soon as possible.
What to Do Outside Your Aetna Health HMO Service Area
Members who are traveling outside their HMO service area or students who are away at school are covered for emergency and urgently needed care. Urgent care may be obtained from a private practice physician, a
walk-in clinic, an urgent care center or an emergency facility. Certain conditions, such as severe vomiting, earaches, sore throats or fever, are considered "urgent care" outside your Aetna Health HMO service area and
are covered in any of the above settings.
If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or emergency problem does not qualify for coverage, it may be necessary to provide us with additional
information. We will send you an Emergency Room Notification Report to complete, or a Member Services representative can take this information by telephone.
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2003 Aetna Health 37 Section 5( d)
Follow-up Care after Emergencies All follow-up care should be coordinated by your PCP. Follow-up care with non-participating providers is only
covered with a referral from your primary care physician and pre-approval from Aetna Health. Whether you were treated inside or outside your Aetna Health service area, you must obtain a referral before any follow-up care can be
covered. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care.
What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, call you primary care doctor. In extreme emergencies or if you are unable to contact your doctor, contact the local emergency system (e. g., the
911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify your primary care doctor. You or a family member must notify your
primary care doctor as soon as possible after receiving emergency care. It is your responsibility to ensure that your primary care doctor has been timely notified.
If you need to be hospitalized, the Plan must be notified as soon as possible. If you are hospitalized in non-Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when
medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-participating providers must be approved by us or provided by plan providers.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified as soon as possible. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges
covered in full.
To be covered by this Plan, any follow-up care recommended by non-participating providers must be approved by us or provided by plan providers.
Benefit Description You pay
Emergency within our service area
.. Emergency care at a doctor's office $20 per PCP visit
$25 per specialist visit
.. Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital the copay is waived.
$100 per visit
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
.. Emergency care at a doctor's office $25 per specialist visit
.. Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital the copay is waived.
$100 per visit
Emergency outside our service area Continued on the next page
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43
2003 Aetna Health 38 Section 5( d)
Emergency outside our service area (Continued) You pay
Not covered: ..
Elective care or non-emergency care ..
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
.. Medical and hospital costs resulting from a normal full-term delivery
of a baby outside the service area.
All charges
Ambulance
Professional ambulance service when medically appropriate. Air ambulance may be covered. Prior approval is required.
See 5( c) for non-emergency service.
Nothing
Not covered: air ambulance without prior approval All charges
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2003 Aetna Health 39 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
Network Benefit
I M
P O
R T
A N
T
Parity
When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits
will be no greater than for similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits: ..
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary. ..
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare. ..
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.
NOTE: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illnesses or conditions.
.. Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social workers ..
Medication management
$25 per visit
.. Diagnostic tests $25 per visit
.. Services provided by a hospital or other facility
.. Services in approved alternative care settings such as partial
hospitalization, full-day hospitalization, facility based intensive outpatient treatment
$25 per outpatient visit
Inpatient service: ..
Approved residential treatment facility ..
Hospital service
$250 per day up to a maximum of $750
per admission
Mental health and substance abuse benefits Continued on the next page
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2003 Aetna Health 40 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Not covered: ..
Services we have not approved ..
Out of network mental health and substance abuse services
NOTE: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to
pay or provide one clinically appropriate treatment plan in favor of another.
All charges
Preauthorization In most areas, certain behavioral health care services (e. g., treatment or care for mental disease or illness, alcohol abuse and/ or substance abuse)
are managed by an independently contracted organization (Behavioral Health Contractor). This organization makes initial coverage
determinations and coordinates referrals; any behavioral health care referrals will generally be made to providers affiliated with the
organization, unless your needs for covered services extend beyond the capability of the affiliated providers. Emergency care is covered (See
Section 5( d), Emergency services/ accidents). You can receive information regarding the appropriate way to access the behavioral
health care services that are covered under your specific plan by calling Member Services at 1-800/ 537-9384 or by calling the Behavioral Health
Contractor number on the front of your ID card. A referral from your PCP is not necessary to access the Behavioral Health Contractor but
your PCP may assist with your referral to the Behavioral Health Contractor.
Network limitation We may limit your benefits if you do not obtain a treatment plan.
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2003 Aetna Health 41 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits: ..
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
.. All benefits are subject to the definitions, limitations and exclusions in this
brochure and are payable only when we determine they are medically necessary.
.. Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
.. Certain drugs require your doctor to get precertification from the Plan before
they can be prescribed under the Plan. Upon approval by the Plan, the prescription is good for the current calendar year or a specified time period,
whichever is less.
I M
P O
R T
A N
T
There are important features you should be aware of. These include: ..
Who can write your prescription. A licensed physician or dentist must write the prescription. ..
Where you can obtain them. You must fill non-emergency prescriptions at a participating Plan retail pharmacy for up to a 30-day supply, or by mail order for a 31-day up to a 90-day supply of medication (if
authorized by your physician). Please call Member Services at 1-800/ 537-9384 for more details on how to use the mail order program. In an emergency or urgent care situation, you may fill your covered
prescription at any retail pharmacy. If you obtain your prescription at a participating pharmacy and request direct reimbursement from us, we will review your claim to determine whether the claim is covered under
the terms and conditions of your benefit plan. If you obtain your prescription at a pharmacy that does not participate with the plan, you will need to pay the pharmacy the full price of the prescription and submit a
claim for reimbursement subject to the terms and conditions of the plan. ..
We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. The Plan's formulary does not exclude medications from coverage, but requires a higher
copayment for nonformulary drugs. Certain drugs require your doctor to get precertification from the Plan before they can be prescribed under the Plan. Visit our website at www. aetna. com/ custom/ fehbp to review
our Formulary Guide or call 1-800/ 537-9384. ..
Precertification. Your pharmacy benefits plan includes our precertification program. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-authorized by
our Pharmacy Management Precertification Unit before they will be covered. Only your physician or pharmacist in the case of an antibiotic or analgesic, can request prior authorization for a drug.
The precertification program is based upon current medical findings, manufacturer labeling, FDA guidelines and cost information.
The drugs requiring precertification are subject to change. Visit our website for the current Precertification List.
.. These are the dispensing limitations. Covered prescription drugs prescribed by a licensed physician or
dentist and obtained at a participating Plan retail pharmacy may be dispensed for up to a 30-day supply. Members must obtain a 31-day up to a 90-day supply of covered prescription medication through mail
order. In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name.
.. Why use generic drugs? Generics contain the same active ingredients in the same amounts as their brand
name counterparts and have been approved by the FDA. By using generic drugs, when available, most members see cost savings, without jeopardizing clinical outcome or compromising quality.
.. When you have to file a claim. Send your itemized bill( s) to: Aetna Health, Pharmacy Management,
Claim Processing, P. O. Box 398106, Minneapolis, MN 55439-8106.
Prescription drug benefits Begin on the next page
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2003 Aetna Health 42 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician or dentist and obtained from a Plan pharmacy or through our
mail order program: ..
Drugs for which a prescription is required by Federal law, except those listed as Not covered
.. Oral contraceptive drugs
.. Insulin
.. Disposable needles and syringes needed to inject covered prescribed
medication ..
Diabetic supplies limited to lancets, alcohol swabs, urine test strips/ tablets, and blood glucose test strips
.. Contraceptive drugs and devices
.. Oral fertility drugs
.. Intravenous fluids and medications for home use, implantable drugs,
IUDs and some injectable drugs are covered under Medical and Surgical benefits. See Section 5( a) for details.
Retail Pharmacy, for up to a 30-day supply per prescription
or refill:
$10 per covered generic formulary drug;
$25 per covered brand name formulary drug; and
$40 per covered non-formulary (generic or brand
name) drug.
Mail Order Pharmacy, for a 31-day up to a 90-day supply
per prescription or refill:
$20 per covered generic formulary drug
$50 per covered brand name formulary drug; and
$80 per covered non-formulary (generic or brand name) drug.
Limited benefits ..
Drugs to treat sexual dysfunction are limited. Contact the Plan for dose limits
.. Depo Provera is limited to 5 vials per calendar year
.. One diaphragm per calendar year
50%
$25 copay per vial
$25 per diaphragm
Here are some things to keep in mind about our prescription drug program: ..
A generic equivalent may be dispensed if it is available, and where allowed by law.
.. To request a copy of the Aetna Health Medication Formulary Guide, call
1-800/ 537-9384. The information in the Medication Formulary Guide is subject to change. As brand name drugs lose their patents and new
generics become available on the market, the brand name drug may be removed from the formulary. Under your benefit plan, this will result in
a savings to you, as you pay a lower prescription copayment for generic formulary drugs. Please visit our website at
www. aetna. com/ custom/ fehbp for current Medication Formulary Guide information.
Covered medications and supplies Continued on the next page
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2003 Aetna Health 43 Section 5( f)
Covered medications and supplies (Continued) You pay
Not covered: ..
Drugs available without a prescription or for which there is a nonprescription equivalent available, (i. e., an over-the-counter (OTC)
drug) ..
Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
.. Vitamins and nutritional substances that can be purchased without
prescription.
.. Medical supplies such as dressings and antiseptics
.. Drugs for cosmetic purposes
.. Drugs to enhance athletic performance
.. Smoking-cessation drugs and medication including, but not limited to,
nicotine patches and sprays
.. Injectable fertility drugs
.. Drugs used for the purpose of weight reduction (i. e., appetite
suppressants)
.. Prophylactic drugs including, but not limited to, anti-malarials for
travel
All charges
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49
2003 Aetna Health 44 Section 5( g)
Section 5 (g). Special features
Feature Description
Services for the deaf and hearing-impaired 1-800/ 628-3323
Informed Health Line Provides eligible members with telephone access to registered nurses experienced in providing information on a variety of health topics.
Informed Health Line is available 24 hours a day, 7 days a week. You may call Informed Health Line at 1-800/ 556-1555. Informed Health Line
nurses cannot diagnose, prescribe medication or give medical advice.
Maternity Management Program Aetna's Moms-to-Babies . Maternity Management Program provides services, information and resources to help improve pregnancy outcomes. Features of the program include a pregnancy risk survey, obstetrical nurse
care coordination, comprehensive educational information on prenatal care, labor and delivery, newborn and baby care, a smoking-cessation
program, and more. To enroll in the program, call toll-free 1-800/ CRADLE-1.
National Medical Excellence Program National Medical Excellence Program helps eligible members access appropriate, covered treatment for solid organ and tissue transplants using
our Institutes of Excellence . network. We coordinate specialized treatment needed by members with certain rare or complicated conditions and assist
members who are admitted to a hospital for emergency medical care when they are traveling temporarily outside of the United States. Services under
this program must be preauthorized.
Reciprocity benefit If you need to visit a participating primary care physician for a covered service, and you are 50 miles or more away from home you may visit a
primary care physician from our plan's approved network.
.. Call 1-800/ 537-9384 for provider information and location
.. Select a doctor from 3 primary care doctors in that area
.. The Plan will authorize you for one visit and any tests or X-rays ordered
by that primary care physician
.. You must coordinate all subsequent visits through your own
participating primary care physician.
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50
2003 Aetna Health 45 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
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Here are some important things to keep in mind about these benefits: ..
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary. ..
Your selected Plan primary care dentist must provide or arrange covered care.
.. We cover hospitalization for dental procedures only when a nondental
physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for inpatient hospital
benefits. We do not cover the dental procedure unless it is described below. ..
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
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Accidental injury benefit
No benefits other than those listed on the following schedule.
Dental Benefits You pay
Service
Diagnostic
Office visit for oral evaluation limited to 2 visits per year
Bitewing x-rays limited to 2 sets of bitewing x-rays per year
Entire x-ray series limited to 1 entire x-ray series in any 3 year period
Periapical x-rays and other dental x-rays as necessary
Diagnostic models
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