CALL ¾ THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

1) Precertification

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

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

2) 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.

3) 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.

4) 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.

Open Access HMO

Aetna offers an Open Access Plan to our members in those FEHBP service areas identified starting on page 9. You can go directly to any network specialist for covered services without a referral from your primary care physician. Note: This does not apply to covered mental health services and/or substance abuse services. Referrals must be obtained for those services. Please see the Mental Health/Substance Abuse section on page 37. Whether your covered services are provided by your selected primary care physician (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). You still should select a PCP and notify Member Services of your selection (1-800/537-9384). If you do not select a PCP, the specialist copay will apply.

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, 1425 Union Meeting Road, P.O. Box 1125, Blue Bell, PA 19422. You may also request replacement cards through our Web site at www.aetna.com/fed.

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.

Ø 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 Web site at www.aetna.com/fed under Provider Directory - DocFind.

To ensure covered services, you must notify Member Services at 1-800/537-9384 of your primary care physician selection.

Ø 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 in the provider directory, which we update periodically. The most current information on our Plan facilities is also on our Web site at www.aetna.com/fed.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member should 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.

Ø 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.

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

Ø Specialty care

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

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

5) If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

6) 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.

7) If you have a chronic and disabling condition and lose access to your specialist because we:

· Terminate our contract with your specialist for other than cause; or

· Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program Plan; or

· Reduce our service area and you enroll in another FEHB Plan,

· you may be able to continue seeing your specialist 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.

Ø 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 Member Services 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:

8) You are discharged, not merely moved to an alternative care center; or

9) The day your benefits from your former plan run out; or

10) The 92^nd day after you become a member of this Plan, whichever happens first.

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

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:

11) For artificial insemination you must contact the Infertility Case Manager at
1-800/575-5999;

12) You must obtain precertification from your primary care doctor and Aetna for covered follow-up care with non-participating providers;

13) You must contact Member Services 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:

14) For surgical treatment of morbid obesity;

15) For select outpatient surgery;

16) For air ambulance;

17) For surgical correction of congenital defects, such as cleft lip and cleft palate;

18) For home IV and antibiotic therapy;

19) For limb and torso prosthetics;

20) For orthognathic surgery and TMJ surgery;

21) For inpatient confinements, skilled nursing facilities, rehabilitation facilities, and inpatient hospice;

22) For covered transplant surgery;

23) When full-time skilled nursing care is necessary in an extended care facility;

24) For non-emergent ambulance transportation service;

25) For certain drugs before they can be prescribed;

26) For growth hormone therapy treatment;

27) For intravenous immunoglobulin (IVIG) therapy treatment;

28) For penile implants;

29) For all home health care services; and

30) 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.

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 $15 per office visit or $20 when you see a participating specialist under High Option and $20 per office visit to your primary care physician, or $30 when you see a participating specialist under Basic Option.

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 allowance that you must pay for your care

Example: In our Plan, you pay 50% of our allowance for infertility services and drugs to treat sexual dysfunction.

Your catastrophic protection out-of-pocket maximum

After your copayments and coinsurance total $1,500/Self Only or $3,000/Self and 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:

31) Prescription drugs

32) Dental services

33) Infertility 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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Here are some important things you should 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.

· If you live or work in an Open Access HMO service area, you should select a PCP by calling Member Services at 1-800/537-9384. If you do not select a PCP and you self-refer to a participating PCP for care, you will pay a specialist copay.

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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

· In an urgent care center for a routine service

· During a hospital stay

· In a skilled nursing facility

$15 per primary care physician (PCP) visit

$20 per specialist visit

$20 per primary care physician (PCP) visit

$30 per specialist visit

· At home

$20 per PCP and specialist visit

$25 per PCP visit

$30 per specialist visit

34) At home visits by nurses and health aides

Nothing

Nothing

Tests, such as:

35) Blood tests

36) Urinalysis

37) Non-routine pap tests

38) Pathology

39) X-rays

40) Non-routine Mammograms

41) CAT Scans/MRI

42) Ultrasound

Nothing if you receive these services during your office visit; otherwise, $15 per PCP visit, $20 per specialist visit

Nothing if you receive these services during your office visit; otherwise, $20 per PCP visit, $30 per specialist visit

43) Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $15 per PCP visit, $20 per specialist visit

Nothing if you receive these services during your office visit; otherwise, $20 per PCP visit, $30 per specialist visit

Routine screenings, such as:

44) Total Blood Cholesterol

45) Routine Prostate Specific Antigen (PSA) test — one annually for men age 50 and older

46) Colorectal Cancer Screening, including

· Fecal occult blood test yearly starting at age 50

· Sigmoidoscopy, screening – every five years starting at age 50

· Double contrast barium enema – every five years starting at age 50

· Colonoscopy screening – every ten years starting at age 50

Note: You may pay either a specialist copay or an outpatient hospital copay depending on where the procedure is performed.

47) Routine well-woman exam, including Pap test, one visit every 12 months from last date of service

Note: No copay for the Pap test if performed on the same day as the office visit

48) Routine physicals

· One exam every 24 months up to age 65

· One exam every 12 months age 65 or older

Routine mammogram — covered for women age 35 and older, as follows:

49) From age 35 through 39, one during this five year period

50) From age 40 through 64, one every calendar year

51) At age 65 and older, one every two consecutive calendar years.

Nothing if you receive these services during your office visit; otherwise, $15 per PCP visit, $20 per specialist visit

Nothing if you receive these services during your office visit; otherwise, $20 per PCP visit, $30 per specialist visit

Routine immunizations, limited to:

52) Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

53) Influenza vaccine, annually

54) Pneumococcal vaccine, age 65 and older

Nothing if provided during the office visit

Nothing if provided during the office visit

Not covered:

55) Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

56) Immunizations and boosters for travel or work-related exposure.

All charges.

All charges.

57) Childhood immunizations recommended by the American Academy of Pediatrics

Nothing

Nothing

58) Well-child care charges for routine examinations, immunizations and care (up to age 22)

59) 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)

$15 per PCP visit

$20 per specialist visit

$20 per PCP visit

$30 per specialist visit

Not covered:

60) Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

61) Immunizations and boosters for travel or work-related exposure.

All charges.

All charges.

Complete maternity (obstetrical) care, such as:

62) Prenatal care

63) Delivery

64) Postnatal care

Note: Here are some things to keep in mind:

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

66) You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary , but you, your representative, your participating doctor, or your hospital must precertify the extended stay.

67) 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.

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

$15 for the first PCP visit only or $20 for the first specialist visit only

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

$20 for the first PCP visit only or $30 for the first specialist visit only

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

Not covered: Routine sonograms to determine fetal age, size or sex.

All charges.

All charges.

A range of voluntary family planning services, limited to:

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

70) Surgically implanted contraceptives

71) Injectable contraceptive drugs, such as Depo Provera

72) Intrauterine devices (IUDs)

73) Diaphragms

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

$15 per PCP visit

$20 per specialist visit

$20 per PCP visit

$30 per specialist visit

Not covered:

1) Reversal of voluntary surgical sterilization

2) Genetic counseling.

All charges.

All charges.

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:

74) Artificial insemination:

· intravaginal insemination (IVI)

· intracervical insemination (ICI)

· intrauterine insemination (IUI)

Note: Coverage is only for 6 cycles (per lifetime). Artificial insemination must be authorized. You must contact the Infertility Case Manager at
1-800/575-5999. You must use our select network of participating Plan infertility providers.

75) Fertility drugs

Note: We cover oral fertility drugs under the prescription drug benefit.

In vitro fertilization is a covered benefit when the following criteria are met:

76) You and your spouse have a history of infertility of at least 2 years duration, or

77) Your oocytes are fertilized with your spouse’s sperm, and

78) Your infertility is associated with endometriosis, exposure in-utero to diethylstilbestrol (DES), blockage of, or surgical removal of, one or both fallopian tubes, or abnormal male factors, including oligospermia contributing to the infertility, and

79) You have been unable to attain a successful pregnancy through a less costly treatment that is covered by the Plan.

50% of all charges

50% of all charges

Note: In vitro fertilization is limited to three attempts per live birth, a maximum lifetime benefit of $100,000. This includes the cost of fertility drugs. We cover oral fertility drugs under the prescription drug benefit. Injectable fertility drugs are covered only for in vitro fertilization.

50% of all charges

50% of all charges

Not covered:

80) Infertility services for couples in which either partner has had a previous sterilization procedure, with or without surgical reversal, and for females who have undergone a hysterectomy.

81) Infertility treatment when the FSH level is 19 mIU/ml or greater on day 3 of menstrual cycle

82) Cost of donor sperm and donor eggs

83) Assisted Reproductive Technology (ART) procedures not shown, such as embryo transfer (frozen), GIFT, ZIFT, sex selection, surrogacy, gene therapy, gestational carriers, cryopreservation, and any other services and supplies related to the non-covered ART procedures

84) Charges associated with care of the donor, such as those required for donor egg retrievals or transfers

85) Charges associated with cryopreservation

86) Charges associated with a gestational carrier program or for the member or the gestational carrier

87) Home ovulation prediction kits

88) Drugs related to the treatment of non-covered benefits or related to the treatment of infertility that are not medically necessary based on current medical standards; including, but not limited to, GnRH agonists, IVIG; and injectable fertility medications not used with in vitro fertilization

89) Charges associated with a frozen embryo transfer including thawing charges

90) Reversal of voluntary, surgically induced sterility

All charges.

All charges.

91) Testing and treatment

92) Allergy injections

Note: You pay the applicable copay for each visit to a doctor’s office including each visit to a nurse for an injection.

$15 per PCP visit

$20 per specialist visit

$20 per PCP visit

$30 per specialist visit

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

All charges.

93) Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 29.

94) Respiratory and inhalation therapy

95) Dialysis – hemodialysis and peritoneal dialysis

96) Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy must be precertified by your Plan physician

97) Growth hormone therapy (GHT)

Note: Growth hormone therapy 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 and it is authorized by Aetna. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$20 per specialist visit

$30 per specialist visit

Twenty visits per condition per member per calendar year for the services of each of the following:

98) qualified physical therapists, and

99) occupational therapists

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

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.

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

$20 per visit, nothing during a covered inpatient admission

$30 per visit, nothing during a covered inpatient admission

Not covered: Long-term rehabilitative therapy

All charges.

All charges.

101) Twenty visits per condition per member per calendar year of pulmonary rehabilitation to treat functional pulmonary disability

102) Cardiac rehabilitation following angioplasty, cardiovascular surgery, chronic heart failure or a myocardial infarction is provided for up to 3 visits a week for a total of 18 visits.

$20 per visit, nothing during a covered inpatient admission

$30 per visit, nothing during a covered inpatient admission

Not covered: Long-term rehabilitative therapy

All charges.

All charges.

103) Habilitative services for children under age 19 with congenital or genetic birth defects including, but not limited to, autism or an autism spectrum disorder, and cerebral palsy. Treatment is provided to enhance the child's ability to function. Services include occupational therapy, physical therapy and speech therapy.

Note: No day or visit limit applies.

$20 per visit, nothing during a covered inpatient admission

$30 per visit, nothing during a covered inpatient admission

104) Twenty visits per condition per member per calendar year

$20 per visit, nothing during a covered inpatient admission

$30 per visit, nothing during a covered inpatient admission

105) Covered for audiological testing and medically necessary treatment for hearing problems

$15 per PCP visit

$20 per specialist visit

$20 per PCP visit

$30 per specialist visit

106) For children up to age 18 — hearing aids, testing, fitting and the examination for them

All charges over $1,400/ear /every 36-month period

All charges over $1,400/ear /every 36-month period

Not covered: All other hearing testing not medically necessary

All charges.

All charges.

107) Treatment of eye diseases and injury

$15 per PCP visit

$20 per specialist visit

$20 per PCP visit

$30 per specialist visit

108) Corrective eyeglasses and frames or contact lenses (hard or soft) per 24 month period.

All charges over $100

All charges over $100

109) 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

$20 per specialist visit

$30 per specialist visit

Not covered:

110) Optic nerve imaging methods including confocal laser scanning tomography, nerve fiber layer testing or analyses, and stereophotogrammetry

111) Fitting of contact lenses

112) Eye exercises

113) Radial keratotomy and laser eye surgery, including related procedures designed to surgically correct refractive errors

All charges.

All charges.

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

Note: See Orthopedic and prosthetic devices for more information

$15 per PCP visit

$20 per specialist visit

$20 per PCP visit

$30 per specialist visit

Not covered:

114) 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

115) Treatment of weak, strained or flat feet; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open manipulation or fixation)

116) Foot orthotics

117) Podiatric shoe inserts

All charges.

All charges.

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

119) Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

120) Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, penile implants, defibrillator, and surgically implanted breast implant following mastectomy, and lenses following cataract removal. Note: See 5(b) for coverage of the surgery to insert the device.

121) Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

122) Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

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

Nothing

Nothing

123) Hair prosthesis for hair loss resulting from radiation therapy or chemotherapy

Nothing up to Plan lifetime maximum of $350; all charges over $350

Nothing up to Plan lifetime maximum of $350; all charges over $350

Not covered:

124) Orthopedic and corrective shoes not attached to a covered brace

125) Arch supports

126) Foot orthotics

127) Heel pads and heel cups

128) Lumbosacral supports

All charges.

All charges.

Rental or purchase, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen equipment. Under this benefit, we also cover:

· Hospital beds (Clinitron and electric beds must be preauthorized);

· Wheelchairs (motorized wheelchairs and scooters must be preauthorized);

· Crutches;

· Walkers; and

· Insulin pumps and related supplies such as needles and catheters.

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

Nothing

Nothing

Not covered:

129) Elastic stockings and support hose

130) Bathroom equipment such as bathtub seats, benches, rails and lifts

131) Home modifications such as stairglides, elevators and wheelchair ramps

132) Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities

All charges.

All charges.

133) 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.

134) Services include oxygen therapy, intravenous therapy and medications.

Note: Short-term physical therapy or occupational therapy accumulate toward the applicable benefit limit (see physical and occupational therapy benefit in this section).

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

Nothing

Nothing

Not covered:

135) Nursing care requested by, or for the convenience of, the patient or the patient’s family.

136) Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

137) Services provided by a family member or resident in the member’s home.

138) Services rendered at any site other than the member’s home.

All charges.

All charges.

Chiropractic services up to 20 visits per member per calendar year

139) Manipulation of the spine and extremities

140) Adjunctive procedures such as ultrasound, electric muscle stimulation, vibratory therapy and cold pack application

$15 per PCP visit

$20 per specialist visit

$20 per PCP visit

$30 per specialist visit

Not covered: Any services not listed above

All charges.

All charges.

No benefits

All charges.

All charges.

We offer the following Aetna disease management programs at no cost to you:

141) Asthma

142) Diabetes

143) Chronic heart failure

144) Low back pain

145) Coronary artery disease

To request more information on our disease management programs, call
1-800/537-9384. Also see the Non-FEHB page for our InteliHealth and Fitness Program.

Nothing

Nothing

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