Page numbers referenced within this brochure apply only to the printed brochure

Aetna Open Access®

www.aetnafeds.com Customer service 800-537-9384

2021



IMPORTANT:
  • Rates
  • Changes for 2021
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization (High Option)

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 7 for details. This Plan is accredited. See page 11.

Serving: Arizona, California, Georgia, and Pennsylvania.

Enrollment in this plan is limited. You must live or work in our geographic service area to enroll. See page 17 for requirements.

Enrollment codes for Phoenix & Tucson, AZ:
WQ1 Self Only
WQ3 Self Plus One
WQ2 Self and Family

Enrollment codes for Los Angeles & San Diego, CA:
2X1 Self Only
2X3 Self Plus One
2X2 Self and Family

Enrollment codes for Athens & Atlanta, GA:
2U1 Self Only
2U3 Self Plus One
2U2 Self and Family

Enrollment codes for Pittsburgh & Western PA:
YE1 Self Only
YE3 Self Plus One
YE2 Self and Family

 

Special Notice: The Plan will reduce its service area for 2021 and no longer offer enrollment code UB for Memphis, TN.

FEHB LogoOPM Logo








Important Notice

Important Notice from Aetna About Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that Aetna's Open Access prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage.  This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

  • Visit www.medicare.gov for personalized help.
  • Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.



Table of Contents

(Page numbers solely appear in the printed brochure)

Table of Content



Introduction

This brochure describes the benefits of our Open Access plan (High option) under Aetna* contract (CS 2867) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at 800-537-9384 or through our website: www.aetnafeds.com.  The address for the Aetna administrative office is:

Aetna
Federal Plans
PO Box 550
Blue Bell, PA 19422-0550

This brochure is the official statement of benefits. No verbal 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 Plus One or 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, 2021, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2021, and changes are summarized on page 18.  Rates are shown at the end of this brochure.

* The Aetna companies that offer, underwrite or administer benefits coverage are Aetna Health Inc., Aetna Health of California Inc., Aetna Life Insurance Company, Aetna Dental Inc., and/or Aetna Dental of California Inc. You are required to receive services from our network of providers.  There are no out-of-network benefits.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand.  Here are some examples,

  • Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means Aetna.
  • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.



Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits 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 that you can do to prevent fraud:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except for your health care providers, authorized health benefits 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) statements that you receive from us.
  • Periodically review your claims history for accuracy to ensure we have not been billed for services you did not receive.
  • 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 800-537-9384 and explain the situation.
    • If we do not resolve the issue:

CALL- THE HEALTH CARE FRAUD HOTLINE
877-499-7295

OR go to

www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy and a quicker response time.

You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100

  • 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)
    • Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26).

A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
  • If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

Aetna complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:

Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Attention:  Assistant Director, FEIO, 1900 E Street NW, Suite 3400-S, Washington, DC 20415-3610




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own health care and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

    • Ask questions and make sure you understand the answers.
    • Choose a doctor with whom you feel comfortable talking.
    • Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

    • Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
    • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
    • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
    • Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected.
    • Read the label and patient package insert when you get your medication, including all warnings and instructions.
    • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
    • Contact your doctor or pharmacist if you have any questions.
    • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

    • Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider’s portal?
    • Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.
    • Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

    • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the health care you need.
    • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

    • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
    • Ask your doctor, “Who will manage my care when I am in the hospital?”
    • Ask your surgeon:
      • "Exactly what will you be doing?"
      • "About how long will it take?"
      • "What will happen after surgery?"
      • "How can I expect to feel during recovery?"
    • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

    • www.jointcommission.org/speakup.aspx. The Joint Commission’s Speak Up™ patient safety program.
    • www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps health care organizations to improve the quality and safety of the care they deliver.
    • www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.
    • www.bemedwise.org The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
    • www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
    • www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a health care facility. These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient services needed to correct Never Events, if you use Aetna preferred providers. This policy helps to protect you from preventable medical errors and improve the quality of care you receive.




FEHB Facts

Coverage information




TermDefinition
  • No pre-existing condition limitation
We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.
  • Minimum essential coverage (MEC)

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

  • Minimum value standard (MVS)
Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.
  • Where you can get information about enrolling in the FEHB Program

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

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

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

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

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, you must also contact your employing or retirement office.

  • Types of coverage available for you and your family

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

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

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

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

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

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

  • Family member coverage

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

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

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

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

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

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have

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

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

  • Children’s Equity Act

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

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

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

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

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

  • When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your
meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

  • When you retire
When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).



When you lose benefits




TermDefinition
  • When FEHB coverage ends

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

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

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

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

  • Upon divorce

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

  • Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26. 

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

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

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

  • Converting to individual coverage

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

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

  • Health Insurance Marketplace

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




Section 1. How This Plan Works

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. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory or visit our website at www.aetnafeds.com.

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 pay only 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.

OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Aetna holds the following accreditations: National Committee for Quality Assurance and/or the local plans and vendors that support Aetna hold accreditation from the National Committee for Quality Assurance. To learn more about this plan’s accreditation(s), please visit the following website:




General features of our High Option

  • You can see participating network specialists without a referral (Open Access).
  • You can choose between our Basic Dental or Dental PPO option.  Under Basic Dental, you can access preventive care for a $5 copay and other services at a reduced fee.  Under the PPO option, if you see an in-network dentist, you pay nothing for preventive care after a $20 annual deductible per member.  You may also utilize non-network dentists for preventive care, but at reduced benefit levels after satisfying the $20 annual deductible per member. You pay all charges for other services when utilizing non-network dentists.
  • You receive a $100 reimbursement every 24 months for glasses or contact lenses.

We have Open Access benefits

 - Does not apply to members in the state of California (Enrollment Code 2X).

Members in the state of California must continue to obtain referrals from their PCPs to access specialist care.  If your primary care physician is part of an IPA, you must be referred to specialists within or approved by that IPA.




Our HMO offers Open Access benefits. This means you can receive covered services from a participating network specialist without a required referral from your primary care physician or by another participating provider in the network.

This Open Access Plan is available to members in our FEHBP service area. If you live or work in an Open Access HMO service area, you can go directly to any network specialist for covered services without a referral from your primary care physician. Note: 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). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection at 800-537-9384. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.




How we pay providers

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 cost-sharing (copayments, coinsurance, deductibles and non-covered services and supplies).

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. 

Specialists, hospitals, primary care physicians and other providers in the Aetna network have agreed to be compensated in various ways:

  • Per individual service (fee-for-service at contracted rates),
  • Per hospital day (per diem contracted rates),
  • Under 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; 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.

One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal. You are encouraged to ask your physicians and other providers how they are compensated for their services.




Your rights and responsibilities

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. 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.

  • Aetna has been in existence since 1850
  • Aetna is a for-profit organization

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, www.aetnafeds.com. You can also contact us to request that we mail a copy to you.

If you want more information about us, call 800-537-9384 or write to Aetna at P.O. Box 550, Blue Bell, PA 19422-0550. You may also visit our website at www.aetnafeds.com.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.aetnafeds.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Medical Necessity

“Medical necessity” means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is:

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

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

Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial letters for such decisions delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal process.

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, one visit per calendar year. The program also allows female members to visit any participating gynecologist for gynecologic problems. Gynecologists may also refer a woman directly to other participating providers for specialized covered gynecologic services. All health plan preauthorization and coordination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG), an Integrated Delivery System (IDS) or a similar organization, your care must be coordinated through the IPA, the PMG, the IDS, or similar organization and the organization may have different referral policies.

Mental Health/Substance Use

Behavioral health services (e.g. treatment or care for mental disease or illness, alcohol abuse and/or substance misuse) are managed by Aetna Behavioral Health. We also make initial coverage determinations and coordinate referrals, if required; 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 these providers. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the terms of your health 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. See section 3, "You need prior plan approval for certain services."

Patient Management

We have developed a patient management program to assist in determining what health care services are covered and payable under the health plan and the extent of such coverage and payment. The program assists members in receiving appropriate health care and maximizing coverage for those health care services.

Where such use is appropriate, our utilization review/patient management staff uses nationally recognized guidelines and resources, such as Milliman Care Guidelines© and InterQual® ISD criteria, to guide the precertification, concurrent review and retrospective review processes. To the extent certain utilization review/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.




TermDefinition
  • 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 you. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments.

Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services. When you are to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment.
  • 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 you 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 you 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 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 phone number.
  • Change your primary care physician or office.
  • Obtain information about how to file a grievance or an appeal.

Privacy Notice

How we guard your privacy - We’re committed to keeping your personal information safe 

What personal information is — and what it isn’t - By “personal information,” we mean that which can identify you. It can include financial and health information. It doesn’t include what the public can easily see. For example, anyone can look at what your plan covers. 

How we get information about you - We get information about you from many sources, including from you. But we also get information from your employer, other insurers, or health care providers like doctors. 

When information is wrong - Do you think there’s something wrong or missing in your personal information? You can ask us to change it. The law says we must do this in a timely way. If we disagree with your change, you can file an appeal. Information on how to file an appeal is on our member website. Or you can call the toll-free number on your ID card. 

How we use this information - When the law allows us, we use your personal information both inside and outside our company. The law says we don’t need to get your permission when we do.

We may use it for your health care or use it to run our plans. We also may use your information when we pay claims or work with other insurers to pay claims. We may use it to make plan decisions, to do audits, or to study the quality of our work.

This means we may share your information with doctors, dentists, pharmacies, hospitals or other caregivers. We also may share it with other insurers, vendors, government offices, or third-party administrators. But by law, all these parties must keep your information private. 

When we need your permission - There are times when we do need your permission to disclose personal information.

This is explained in our Notice of Privacy Practices, which took effect October 9, 2018. This notice clarifies how we use or disclose your Protected Health Information (PHI):

  • For workers’ compensation purposes
  • As required by law
  • About people who have died
  • For organ donation
  • To fulfill our obligations for individual access and HIPAA compliance and enforcement 

To get a copy of this notice, just visit our member website. Or call the toll-free number on your ID card.

If you want more information about us, call 800-537-9384, or write to Aetna, Federal Plans, PO Box 550, Blue Bell, PA 19422-0550. You may also contact us by fax at 860-975-1669 or visit our website at www.aetnafeds.com.




Aetna HMO Service Area

To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:

California, Los Angeles & San Diego areas – Enrollment code 2X – Los Angeles, Orange, San Diego, San Luis Obispo, 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 and Mesa Verde

San Bernardino County: All towns except Baker, Big River, Cadiz, Cima, Danby, Earp, Essex, Ivonpah, Kelso, Lake Havasu, Needles, Nipton, Parker Dam, Rice and Vidal.




Aetna Open Access Service Area

The following service areas will be for our Aetna Open Access HMO. Under these plans, members may see network specialists without obtaining a referral from their primary care physician (PCP). To enroll in this Plan, you must live in or work in our service area.  You are required to receive services from our network of providers.  There are no out-of-network benefits.  This is where our providers practice. Our service area is:

Arizona, Phoenix and Tucson areas– Enrollment code WQ – Cochise, Graham, Gila, Maricopa, Mohave, Pima, Santa Cruz, Yavapai and Yuma counties and portions of the following county as defined by the towns below:

Pinal: Apache Junction, Casa Grande, Coolidge, Eloy, Florence, Kearny, Maricopa, Picacho, Queen Creek, Red Rock, Sacaton, Stanfield and Superior.

Georgia, Athens and Atlanta areas – Enrollment code 2U – Barrow, Bartow, Butts, Carroll, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Floyd, Forsyth, Fulton, Gordon, Greene, Gwinnett, Hall, Heard, Henry, Jackson, Jasper, Lamar, Morgan, Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Polk, Rockdale, Spalding and Walton counties.

Pennsylvania, Pittsburgh and Western PA areas– Enrollment code YE – Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, Mckean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland 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 or urgent 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), they will be able to access full HMO benefits if they reside in any Aetna HMO service area by selecting a PCP in that service area. If not, 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.




Section 2. Changes for 2021

Do not rely only on these change descriptions; this Section 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.

Changes to High Option

  • Enrollment Code 2U. Your share of the non-Postal premium will increase for Self Only, increase for Self Plus One, and increase for Self and Family. See page 98.
  • Enrollment Code 2X. Your share of the non-Postal premium will increase for Self Only, increase for Self Plus One, and increase for Self and Family. See page 97.
  • Enrollment Code WQ. Your share of the non-Postal premium will increase for Self Only, increase for Self Plus One, and increase for Self and Family. See page 97.
  • Enrollment Code YE. Your share of the non-Postal premium will decrease for Self Only, decrease for Self Plus One, and decrease for Self and Family. See page 98.
  • Services that require plan approval (other services) – The Plan updated its list of services that require plan approval. Services that now must be preauthorized are: Functional endoscopic sinus surgery, Arthrodesis for spine deformity and Kyphectomy. (See page 21)
  • Specialty drugs - The Plan will now require members to fill all specialty drugs at an Aetna Performance Specialty Network pharmacy. (See page 62)
  • True accumulation for specialty drugs - The Plan will now apply true accumulation. Some specialty medications may qualify for third-party copayment assistance programs that could lower your out of-pocket costs for those products. For any such specialty medication where third-party copayment assistance is used, the member shall not receive credit toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. (See page 64)
  • Voluntary maintenance choice - Through voluntary maintenance choice, members can fill maintenance drugs (30-90 day supply) either through home delivery or at CVS pharmacy retail locations. (See page 64)



Section 3. How You Get Care

TermDefinition

Open Access HMO

This Open Access Plan is available to our members in those FEHBP service areas identified starting on page 17. You can go directly to any network specialist for covered services without a referral from your primary care physician. 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). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.

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 letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

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

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance and you will not have to file claims.  If you use our Open Access program you can receive covered services from a participating network provider without a required referral from your primary care physician or by another participating provider in the network.

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.aetnafeds.com under our online provider directory.

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 website at www.aetnafeds.com.

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.

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 website. We will help you select a new one.

Specialty care

If you are enrolled in Enrollment Code 2X, 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. Your primary care physician may refer you to any participating specialist for other specialty care. If your primary care physician is part of an IPA, you will be referred to IPA-approved specialists.  When you receive a referral from your primary care physician, you must return to the 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, one visit every 12 months from the last date of service, 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 some other things you should know about specialty care:

  • For CA (code 2X) only, 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).
  • Your primary care physician will create your treatment plan.  The physician may have to get an authorization or approval from us beforehand.  If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. 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 and disabling condition and lose access to your specialist because we:
    • terminate our contract with your specialist for other than cause
    • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
    • reduce our Service Area and you enroll in another FEHB plan

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

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

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 hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services department immediately at 800-537-9384. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

You need prior Plan approval for certain services

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

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

Inpatient hospital admission

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

  • Other services

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

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

*For complete list refer to:
www.aetna.com/health-care-professionals/precertification/precertification-lists.html or the Behavioral Health Precertification list. The specialty medication precertification list can be found at: www.aetnafeds.com/pharmacy.

Members must call 800-537-9384 for authorization.

How to request precertification for an admission or get prior authorization for Other services

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

Next, provide the following information:

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

Non-urgent care claims

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

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

  • Urgent care claims

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

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

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

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

  • Concurrent care claims

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

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

Emergency inpatient admission

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

Maternity care

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

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

  • If your treatment needs to be extended

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

Circumstances beyond our controlUnder certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.  In that case, we will make all reasonable efforts to provide you with the necessary care.
If you disagree with our pre-service claim decision

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

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

To reconsider a non-urgent care claim

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

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

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

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

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

  3.  Write to you and maintain our denial.

To reconsider an urgent care claim

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

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

To file an appeal with OPM

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

The Federal Flexible Spending Account Program - FSAFEDS

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



Section 4. Your Cost for Covered Services

This is what you will pay out-of-pocket for covered care:



TermDefinition
Cost-sharing Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.
Copayments

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

Example: When you see your primary care physician, you pay a copayment of $20 per office visit, or a copayment of $35 per office visit when you see a participating specialist.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

  • We have a deductible of $20 per member per year if you elect our PPO dental option.

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

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. 

Example: In our Plan, you pay 30% of our allowance for durable medical equipment.

Differences between our Plan allowance and the bill
  • Network Providers agree to accept our Plan allowance so if you use a network provider, you never have to worry about paying the difference between our Plan allowance and the billed amount for covered services.
  • Non-Network Providers (for Dental PPO Option only): If you use a non-network provider for preventive dental care, you will have to pay 50% of our negotiated rate and the difference between our Plan allowance and the billed amount.

Your catastrophic protection out-of-pocket maximum

After your (copayments and coinsurance) total $5,000 for Self Only or $10,000 for Self Plus One, or $10,000 for Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment the plan will begin to cover eligible medical expenses at 100%. The remaining balance of the Self Plus One or Self and Family out-of-pocket maximum can be satisfied by one or more family members. However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

  • Dental services (Note: $5 copayments for DMO preventive care and $20 deductible for PPO preventive care count towards your out-of-pocket maximum.  All other dental service expenses do not count toward your out-of-pocket maximum). 

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

Carryover

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

When Government facilities bill usFacilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow.  You may be responsible to pay for certain services and charges.  Contact the government facility directly for more information.



High Option Benefits (High Option)

See page 18 for how our benefits changed this year. Pages 95-96 is a benefits summary of our High Option.




(Page numbers solely appear in the printed brochure)

Table of Content



Section 5. High Option Benefits Overview (High Option)

This Plan offers only a High Option. Our benefit package is described in Section 5. Make sure that you review the benefits carefully.

The High Option Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. 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 Open Access benefits, contact us at 800-537-9384 or on our website at www.aetnafeds.com.

Our benefit package offers the following unique features:

  • You can see participating network specialists without a referral (Open Access), except for California.
  • You have more choices for your dental coverage. You can choose between our Advantage Dental or our Dental PPO option. Under Advantage Dental, you can access preventive care for a $5 copay and other services at a reduced fee. Under the PPO option, if you see an in-network dentist, you pay nothing for preventive care after a $20 annual deductible per member. Participating network PPO dentists may offer members other services at discounted fees. Discounts may not apply in all states. You may also utilize non-network dentists for preventive care, but at reduced benefit levels, and after a $20 annual deductible per member. You pay all charges for other services when utilizing non-network dentists.
  • You receive a $100 reimbursement every 24 months for glasses or contact lenses.
  • You can use Aetna Health Connections Disease Management Programs which are available for thirty-four conditions.



Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals (High Option)

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.
  • A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
  • 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 Aetna Open Access HMO service area, you should select a PCP by calling Member Services at 800-537-9384.
  • If you live or work in an Aetna Open Access HMO service area, you do not have to obtain a referral from your PCP to see a specialist (does not apply to enrollment code 2X).



Benefit Description : Diagnostic and treatment servicesHigh Option (You pay )

Professional services of physicians

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

$20 per primary care physician (PCP) visit

$35 per specialist visit

  • During a hospital stay
  • In a skilled nursing facility
Nothing
  • In an urgent care center
$50 per visit
  • At home

$25 per PCP visit

$35 per specialist visit

Benefit Description : Telehealth servicesHigh Option (You pay )
  • Teladoc

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

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

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

$35 per consult
Benefit Description : Lab, X-ray and other diagnostic testsHigh Option (You pay )

Tests, such as:

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

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

$20 per PCP visit

$35 per specialist visit

Diagnostic tests limited to:

  • Bone density tests - diagnostic
  • CT scans/MRIs/PET scans
  • Diagnostic angiography
  • Genetic testing - diagnostic*
  • Nuclear medicine

Note: The services need precertification. See "Services requiring our prior approval" on pages 21-22.

*Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient's medical condition.

$75 copay
  • Genetic Counseling and Evaluation for BRCA Testing
  • Genetic Testing for BRCA-Related Cancer*

*Note: Requires precertification. See "Services requiring our prior approval" on pages 21-22.

Nothing
Benefit Description : Preventive care, adultHigh Option (You pay )
  • Routine physicals - one (1) exam every calendar year

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

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/ 
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
Nothing

Routine mammogram - covered for women.

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

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Not covered:

  • Physical exams, immunizations and boosters required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
  • Immunizations, boosters, and medications for travel or work-related exposure.
All charges
Benefit Description : Preventive care, childrenHigh Option (You pay )
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

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

Nothing
  • Well-child care charges for routine examinations, immunizations and care (up to age 22)
    • Seven (7) routine exams from birth to age 12 months
    • Three (3) routine exams from age 12 months to 24 months
    • Three (3) routine exams from age 24 months to 36 months
    • One (1) routine exam per year thereafter to age 22
  • Examinations such as:
    • Vision screenings through age 17 to determine the need for vision correction*
    • Hearing exams through age 17 to determine the need for hearing correction
    • Routine examinations done on the day of immunizations (up to age 22)

*For routine eye refraction, see Vision Services 

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Not covered:

  • Physical exams, immunizations and boosters required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
All charges
Benefit Description : Maternity careHigh Option (You pay )

Complete maternity (obstetrical) care, such as:

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

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

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

  • Screening for gestational diabetes for pregnant women.
  • Delivery
  • Postnatal care

Note: Here are some things to keep in mind:

  • You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
  • You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will extend your inpatient stay if medically necessary, but you, your representative, your participating doctor, or your hospital must precertify the extended stay.
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay including the initial examination of a newborn child covered under a Self Plus One or Self and Family enrollment. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
  • We pay hospitalization and surgeon services for maternity care (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

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

Note: Also see our Maternity Management Program (Aetna’s Beginning Right ® Maternity Program) in Section 5 (h).

No copay for prenatal care or the first postpartum care visit

$20 for PCP visit or $35 for specialist visit for postpartum care visits thereafter

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

Breastfeeding support, supplies and counseling for each birthNothing
Not covered:  Home birthsAll charges
Benefit Description : Family planning High Option (You pay )

A range of voluntary family planning services limited to:

  • Contraceptive counseling on an annual basis
  • Voluntary sterilization (See Surgical procedures Section 5 (b))
  • Surgically implanted contraceptives
  • Generic injectable contraceptive drugs
  • Intrauterine devices (IUDs)
  • Diaphragms
Note:  We cover injectable contraceptives under the medical benefit when supplied by and administered at the provider's office.  Injectable contraceptives are covered at the prescription drug benefit when they are dispensed at the Pharmacy.  If a member must obtain the drug at the pharmacy and bring it to the provider's office to be administered, the member would be responsible for both the Rx and office visit copayments.  We cover oral contraceptives under the prescription drug benefit.

Nothing for women

For men:
$20 per PCP visit
$35 for Specialist visit

Not covered:

  • Reversal of voluntary surgical sterilization
  • Genetic testing and counseling
All charges
Benefit Description : Infertility servicesHigh Option (You pay )

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

Diagnosis and treatment of infertility such as:

  • Testing for diagnosis and surgical treatment of the underlying medical cause of infertility
$35 per specialist visit

Not covered:

  • Any assisted reproductive technology (ART) procedure or services related to such procedures, including but not limited to in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and intra-cytoplasmic sperm injection (ICSI) or
  • Artificial insemination (AI) and monitoring of ovulation:
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI) or
  • Any charges associated with care required to obtain Artificial insemination or ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for any Artificial insemination or ART procedures
  • Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services.
  • Services and supplies related to the above mentioned services, including sperm processing
  • Services associated with cryopreservation or storage of cryopreserved eggs and embryos (e.g, office, hospital, ultrasounds, laboratory tests etc)
  • The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers (or surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational carrier;
  • Reversal of sterilization surgery.
  • Treatment for infertility when the cause of the infertility was a previous sterilization with or without surgical reversal
  • Injectable fertility drugs, including but not limited to menotropins, hCG, GnRH agonists, and IVIG
  • Cost of home ovulation predictor kits or home pregnancy kits
  • Drugs related to the treatment of non-covered benefits
  • Infertility services that are not reasonably likely to result in success
All charges
Benefit Description : Allergy careHigh Option (You pay )
  • Testing and treatment
  • 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.

$20 per PCP visit

$35 per specialist visit

Allergy serumNothing
Not covered:  Provocative food testing and Sublingual allergy desensitization All charges
Benefit Description : Treatment therapiesHigh Option (You pay )
  • 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 45.

  • Respiratory and inhalation therapy
  • Dialysis-hemodialysis and peritoneal dialysis

Note: Copayment does not apply for peritoneal dialysis when self administered. Copayment will apply if services are rendered in the home by a plan provider.

  • Intravenous (IV) Infusion Therapy in a doctor's office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services.)
  • Growth hormone therapy (GHT)

Note: Growth hormone therapy is covered under Medical Benefits; office copay applies. We cover growth hormone injectables under the prescription drug benefit.

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

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

$35 per visit

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

Benefit Description : Physical and occupational therapiesHigh Option (You pay )

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

  • Qualified Physical therapists
  • Occupational therapists

Note:  We only cover therapy when a physician:

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

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

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

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

$35 per visit

Nothing during a covered inpatient admission

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

Not covered:

  • Long-term rehabilitative therapy
All charges
Benefit Description : Pulmonary and cardiac rehabilitationHigh Option (You pay )
  • Two (2) consecutive months (60 consecutive days) per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability.
  • Cardiac rehabilitation following a qualifying event/condition is provided for up to three (3) visits a week for a total of 18 visits.

$35 per visit

Nothing during a covered inpatient admission

Not covered: Long-term rehabilitative therapy All charges
Benefit Description : Habilitative TherapyHigh Option (You pay )
  • Habilitative services for congenital or genetic birth defects including, but not limited to, autism or an autism spectrum disorder, and developmental delays. Treatment is provided to enhance the ability to function. Services include occupational therapy, physical therapy and speech therapy.

$35 per visit

Nothing during a covered inpatient admission

Benefit Description : Speech therapy High Option (You pay )
  • 60 visits per person, per calendar year

$35 per visit

Nothing during a covered inpatient admission

Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You pay )
  • Audiological testing and medically necessary treatment for hearing problems
  • Hearing testing for children through age 17 (see Preventive care, children)
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants. (See Orthopedic and prosthetic devices section and the note referring to Section 5(b) and 5(c) for hospital and ambulatory surgery center benefits).

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

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

$20 per PCP visit

$35 per specialist visit

Not covered:

  • Hearing aids, testing and examinations for them
  • Hearing services that are not shown as covered
All charges
Benefit Description : Vision services (testing, treatment, and supplies)High Option (You pay )
  • Treatment of eye diseases and injury

$20 per PCP visit

$35 per specialist visit

  • Corrective eyeglasses and frames or contact lenses (hard or soft) for adults age 19 and older once per 24 month period.
All charges over $100
  • Corrective eyeglasses and frames or contact lenses (hard or soft)  for children through age 18 once per 24 month period.
Note: You must pay for charges above the $100 allowance and submit a claim form for reimbursement of the 10%.
90% of charges after $100

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

Note: See Preventive Care, Children for eye exams for children

$35 per specialist visit

Not covered:

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

All charges

Benefit Description : Foot careHigh Option (You pay )
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

$20 per PCP visit

$35 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; 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
Benefit Description : Orthopedic and prosthetic devices High Option (You pay )
  • Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes. Limb and torso prosthetics must be preauthorized.
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Ostomy supplies specific to ostomy care (quantities and types vary according to the ostomy, location, construction, etc.)

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

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

Note: For information on the professional charges for the surgery to insert an implant or internal prosthetic device, see Section 5(b) Surgical procedures. For information regarding facility fees associated with obtaining orthopedic and prosthetic devices, see Section 5(c).

30% of our Plan allowance
  • Hair prosthesis prescribed by a physician for hair loss resulting from radiation therapy, chemotherapy or certain other injuries, diseases, or treatment of a disease.
Nothing up to Plan lifetime maximum of $500; all charges over $500

Not covered:

  • Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
  • Lumbosacral supports
  • All charges over $500 for hair prosthesis
All charges
Benefit Description : Durable medical equipment (DME)High Option (You pay )

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

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

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

30% of our Plan allowance

Not covered:

  • Elastic stockings and support hose
  • Bathroom equipment such as bathtub seats, benches, rails and lifts
  • Home modifications such as stair glides, elevators and wheelchair ramps
  • Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities
All charges
Benefit Description : Home health servicesHigh Option (You pay )
  • Home health services ordered by a Plan Physician and provided by nurses and home health aides through a participating home health care agency. Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less. The Plan will allow up to 60 visits per member per calendar year. Your Plan Physician will periodically review the program for continuing appropriateness and need.
  • Services include oxygen therapy.

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

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

$90 per visit

Intravenous (IV) Infusion Therapy and medications

 

$35 per visit

Not covered:

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

Chiropractic services up to 20 visits per member per calendar year

  • Manipulation of the spine and extremities
  • Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
$35 per specialist visit

Not covered:

  • Any services not listed above
All charges
Benefit Description : Alternative medicine treatmentsHigh Option (You pay )

Acupuncture - 20 visits per member per calendar year.

Note: See page 51 for our coverage of acupuncture when provided as anesthesia for covered surgery.

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

$35 per visit

Nothing when provided as anesthesia for covered surgery

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

  • Acupuncture other than stated above
  • Applied kinesiology
  • Aromatherapy
  • Biofeedback
  • Craniosacral therapy
  • Hair analysis
  • Reflexology
All charges
Benefit Description : Educational classes and programsHigh Option (You pay )

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

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

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

Nothing

Coverage is provided for:

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

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

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

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




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals (High Option)

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.
  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care.  See 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.



Benefit Description : Surgical proceduresHigh Option (You pay )

A comprehensive range of services, such as:

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

We will consider:

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

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

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

* Subject to medical necessity
** Note: Requires Precertification. See “Services requiring our prior approval” on pages 21-22. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

$20 per PCP visit

$35 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.
Voluntary sterilization for women (e.g., tubal ligation)Nothing

Not covered:

  • Reversal of voluntary surgically-induced sterilization
  • Surgery primarily for cosmetic purposes
  • Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
  • Routine treatment of conditions of the foot (see Foot care)
  • Gender reassignment services that are not considered medically necessary
All charges
Benefit Description : Reconstructive surgery High Option (You pay )
  • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • the condition produced a major effect on the member’s appearance and
    • the condition can reasonably be expected to be corrected by such surgery
  • Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital and developmental anomalies are cleft lip, cleft palate,  webbed fingers, and webbed toes. All surgical requests must be preauthorized.
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • surgery to produce a symmetrical appearance of breasts
    • treatment of any physical complications, such as lymphedema
    • breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

$35 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
All charges
Benefit Description : Oral and maxillofacial surgery High Option (You pay )

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

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

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

$35 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

Not covered:

  • Dental implants
  • Dental care (such as restorations) involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
All charges
Benefit Description : Organ/tissue transplantsHigh Option (You pay )

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on pages 21-22.

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

$35 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

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

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

$35 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

Blood or marrow stem cell transplants

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

The Plan extends coverage for the diagnoses as indicated below.

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

*Approved clinical trial necessary for coverage.

$35 per specialist visit

Nothing for the surgery. See section 5(c) for facility charges.

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

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

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

$35 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

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

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

  • Allogeneic transplants for:
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Beta Thalassemia Major
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Sickle Cell anemia
  • Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    •  Breast cancer 
    • Chronic lymphocytic leukemia
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Colon cancer 
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Myelodysplasia/Myelodysplastic Syndromes
    • Myeloproliferative disorders (MPDs)
    • Non-small cell lung cancer
    • Ovarian cancer
    • Prostate cancer
    • Renal cell carcinoma
    • Sarcomas
    • Sickle cell anemia
  • Autologous Transplants for:
    • Advanced childhood kidney cancers
    • Advanced Ewing sarcoma
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Aggressive non-Hodgkin lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms) 
    • Breast cancer
    • Childhood rhabdomyosarcoma 
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Epithelial ovarian cancer
    • Mantle Cell (Non-Hodgkin lymphoma) 
    • Multiple sclerosis
    • Small cell lung cancer
    • Systemic lupus erythematosus
    • Systemic sclerosis
  • National Transplant Program (NTP) - Transplants which are non-experimental or non-investigational are a covered benefit. Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery. The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures. A transplant is non-experimental and non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate treatment for your specific condition. Coverage for a transplant where you are the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.

*Note: Transplants must be performed at hospital designated as Institutes of Excellence (IOE). Hospitals in our network, but not designated as an IOE hospital will not be covered.

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

$35 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

Clinical trials must meet the following criteria:

A. The member has a current diagnosis that will most likely cause death within one year or less despite therapy with currently accepted treatment; or the member has a diagnosis of cancer; AND

B. All of the following criteria must be met:

1. Standard therapies have not been effective in treating the member or would not be medically appropriate; and

2. The risks and benefits of the experimental or investigational technology are reasonable compared to those associated with the member's medical condition and standard therapy based on at least two documents of medical and scientific evidence (as defined below); and

3. The experimental or investigational technology shows promise of being effective as demonstrated by the member’s participation in a clinical trial satisfying ALL of the following criteria:

a. The experimental or investigational drug, device, procedure, or treatment is under current review by the FDA and has an Investigational New Drug (IND) number; and

b. The clinical trial has passed review by a panel of independent medical professionals (evidenced by Aetna’s review of the written clinical trial protocols from the requesting institution) approved by Aetna who treat the type of disease involved and has also been approved by an Institutional Review Board (IRB) that will oversee the investigation; and

c. The clinical trial is sponsored by the National Cancer Institute (NCI) or similar national cooperative body (e.g., Department of Defense, VA Affairs) and conforms to the rigorous independent oversight criteria as defined by the NCI for the performance of clinical trials; and

d. The clinical trial is not a single institution or investigator study (NCI designated Cancer Centers are exempt from this requirement); and

4. The member must:

a. Not be treated “off protocol,” and

b. Must actually be enrolled in the trial.

$35 per specialist visit

Nothing for the surgery.  See section 5(c) for facility charges.

Not covered:

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

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

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

Note: For sedation or anesthesia relating to dental services performed in a dental office, see Section 5(g), Dental benefits.

Note: When the anesthesiologist is the primary giver of services, such as for pain management, the specialist copay applies.

Nothing



Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (High Option)

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 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 in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.
  • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.



Benefit Description : Inpatient hospitalHigh Option (You pay)

Room and board, such as:

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

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

Other hospital services and supplies, such as:

  • Operating, recovery, maternity, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and X-rays
  • Administration of blood and blood products
  • Blood products, derivatives and components, artificial blood products and biological serum. Blood products include any product created from a component of blood such as, but not limited to, plasma, packed red blood cells, platelets, albumin, Factor VIII, Immunoglobulin, and prolastin
  • Dressings, splints, casts, and sterile tray services
  • Medical supplies and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services
  • Take-home items
  • Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.
$250 per day up to a maximum of $1,000 per admission

Not covered:

  • Whole blood and concentrated red blood cells not replaced by the member
  • Non-covered facilities, such as nursing homes and schools
  • Custodial care, rest cures, domicilary or convalescent cares
  • Personal comfort items, such as phone and television
  • Private duty nursing
All charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You pay)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • Radiologic procedures, diagnostic laboratory tests, and X-rays when associated with a medical procedure being done the same day
  • Pathology Services
  • Administration of blood, blood plasma, and other biologicals
  • Blood products, derivatives and components, artificial blood products and biological serum
  • Pre-surgical testing
  • Dressings, casts, and sterile tray services
  • Medical supplies, including oxygen
  • Anesthetics and anesthesia service
  • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.

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

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

Note: Preventive care services are not subject to copays listed.

$175 per visit

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

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

* See below for exceptions

$35 per specialist visit

Complex diagnostic tests limited to:

  • Bone density tests - diagnostic
  • CT scans/MRIs/PET scans
  • Diagnostic angiography
  • Genetic testing - diagnostic*
  • Nuclear medicine

Note: These services need precertification. See "Services requiring our prior approval" on pages 21-22.

*Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient's medical condition.

$75 copay

Not covered:

  • Whole blood and concentrated red blood cells not replaced by the member
All charges
Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHigh Option (You pay)
Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 60-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.30% of our Plan allowance
    Not covered: Custodial care All charges
Benefit Description : Hospice careHigh Option (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 six (6) months or less.

$5 copay

Benefit Description : AmbulanceHigh Option (You pay)

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

  1. Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or 
  2. To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or
  3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
  4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

Ambulance - $100 copay

Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day.

Not covered:

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

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

All charges



Section 5(d). Emergency Services/Accidents (High Option)

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.
  • 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.
  • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.



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:

Emergencies within our Service Area:

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 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. For non-emergency services, care may be obtained from a retail clinic, a walk-in clinic, an urgent care center or by calling Teladoc. If a delay would not be detrimental to your health, call your primary care physician. Notify your primary care physician as soon as possible after receiving treatment.
  • After assessing and stabilizing your condition, the emergency facility should contact your primary care physician so he/she 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 Aetna as soon as possible.

Emergencies outside our Service Area:

If you are traveling outside your Aetna service area or if you are a student who is away at school, you are covered for emergency and urgently needed care. For non-emergency services, care may be obtained from a walk-in clinic, an urgent care center or by calling Teladoc. Urgent care may be obtained from a private practice physician, a walk-in clinic, an urgent care center. Certain conditions, such as severe vomiting, earaches, or high fever are considered “urgent care” outside your Aetna 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 phone.


Follow-up Care after Emergencies

All follow-up care should be coordinated by your PCP or network specialist. Follow-up care with non-participating providers is only covered with a referral from your primary care physician and pre-approval from Aetna. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care.





Benefit Description : Emergency within our service areaHigh Option (You pay )
Emergency or urgent care at a doctor’s office

$20 per PCP visit

$35 per specialist visit

Emergency or urgent care at an urgent care center$50 per visit
Emergency care as an outpatient at a hospital (Emergency Room), including doctors’ services.

$125 per visit

Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

Not covered: Elective care or non-emergency care

All charges

Benefit Description : Emergency outside our service areaHigh Option (You pay )
Emergency or urgent care at a doctor’s office$35 per specialist visit
Emergency or urgent care at an urgent care center$50 per visit
Emergency care as an outpatient at a hospital (Emergency Room), including doctors’ services.

$125 per visit

Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

Not covered:

  • Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
  • Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area
All charges
Benefit Description : Telehealth servicesHigh Option (You pay )
  • Teladoc

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

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

$35 per consult
Benefit Description : AmbulanceHigh Option (You pay )

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

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

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

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

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

Air or sea ambulance may be covered. Prior approval is required.

Note: See 5(c) for non-emergency service.

Ambulance - $100 copay

Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day.

Not covered:

  • Ambulance transportation to receive outpatient or inpatient services and back home again, except in an emergency.
  • Ambulette service.
  • Air ambulance without prior approval.
  • Ambulance transportation for member convenience or for reasons that are not medically necessary.

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

All charges



Section 5(e). Mental Health and Substance Use Disorder Benefits (High Option)

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.
  • 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 FOR CERTAIN SERVICES. Benefits are payable only when we determine the care is clinically appropriate to treat your condition. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan. Please see Section 3 of this brochure for a list of services that require preauthorization.
  • Aetna can assist you in locating participating providers in the Plan, 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 800-537-9384. A referral from your PCP is not necessary to access behavioral health care but your PCP may assist in coordinating
    your care.
  • We will provide medical review criteria for denials to enrollees, members or providers upon request or as otherwise required.
  • 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.



Benefit Description : Professional servicesHigh Option (You pay )

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

  • Psychiatric office visits to Behavioral Health practitioner
  • Substance Use Disorder (SUD) office visits to Behavioral Health practitioner
  • Routine psychiatric office visits to Behavioral Health practitioner
  • Behavioral therapy

$35 per visit
  • Telemedicine Behavioral Health consult

$35 per visit

Skilled behavioral health services provided in the home, but only when all of the following criteria are met:

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

$35 per visit

Applied Behavior Analysis (ABA)

The plan covers medically necessary Applied Behavior Analysis (ABA) therapy when provided by network behavioral health providers. These providers include:

    • Providers who are licensed or who possess a state-issued or state-sanctioned certification in ABA therapy.
    • Behavior analysts certified by the Behavior Analyst Certification Board (BACB).
    • Registered Behavior Technicians (RBTs) certified by the BACB or equivalent paraprofessionals who work under the supervision of a licensed provider or a certified behavior analyst.

Note: Requires Precertification. See “Services requiring our prior approval” on pages 21-22. You are responsible for ensuring that we are asked to precertify your care. You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

$35 per visit
Benefit Description : DiagnosticsHigh Option (You pay )
  • Psychological and Neuropsychological testing provided and billed by a licensed mental health and SUD treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
$35 per outpatient visit
Benefit Description : Inpatient hospital or other covered facilityHigh Option (You pay )

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

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility
$250 per day up to a maximum of $1,000 per admission
Benefit Description : Outpatient hospital or other covered facilityHigh Option (You pay )

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

  • Partial hospitalization treatment provided in a facility or program for mental health treatment provided under the direction of a physician
  • Intensive outpatient program provided in a facility or program for mental health treatment provided under the direction of a physician
  • Outpatient detoxification
  • Ambulatory detoxification which is outpatient services that monitor withdrawal from alcohol or other substance abuse, including administration of medications
  • Treatment of withdrawal symptoms
  • Electro-convulsive therapy (ECT)
  • Mental health injectables
  • Substance abuse injectables
  • Transcranial magnetic stimulation (TMS)
$35 per outpatient visit
Benefit Description : Not coveredHigh Option (You pay )
  • Educational services for treatment of behavioral disorders
  • Services in half-way houses
All charges



Section 5(f). Prescription Drug Benefits (High Option)

Important things you should keep in mind about these benefits:

This is a five-tier open formulary pharmacy plan, Advanced Control Formulary. The formulary is a list of drugs that your health plan covers. With your Advanced Control Formulary Pharmacy plan, each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Each tier has a separate out-of-pocket cost.

    • Preferred generic
    • Preferred brand
    • Non-preferred generic and brand
    • Preferred specialty
    • Non-preferred specialty
  • We cover prescribed drugs and medications, as described in the chart beginning on the next page.
  • 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.

  • Federal law prevents the pharmacy from accepting unused medications.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
  • 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 covered under the Plan. Upon approval by the Plan, the prescription is covered for the current calendar year or a specified time period, whichever is less.



There are important features you should be aware of. These include:

  • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice.
  • Where you can obtain them. You must fill 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). You may obtain up to a 30-day supply of medication for one copay, (retail pharmacy) and for a 31-day up to a 90-day supply of medication for two copays (mail order). In no event will the copay exceed the cost of the prescription drug. For retail pharmacy transactions, you must present your Aetna Member ID card at the point of sale for coverage. Please call Member Services at 800-537-9384 for more details on how to use the mail order program. Mail order is not available for drugs and medications ordered through a network Specialty Pharmacy. Prescriptions ordered through a network Specialty Pharmacy are only filled for up to a 30-day supply due to the nature of these prescriptions. In an emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. If you obtain your emergency 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. The formulary is a list of drugs that your Plan covers. Drugs are prescribed by licensed doctors and covered in accordance with the 2021 Pharmacy Drug (Formulary) Guide. Certain drugs require your doctor to get precertification or step therapy from the Plan before they can be covered under the Plan. Your prescription drug plan includes drugs listed in the 2021 Pharmacy Drug (Formulary) Guide. Prescription drugs listed on the formulary exclusions list are excluded unless a medical exception is approved by the Plan. If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at www.aetnafeds.com to review our 2021 Pharmacy Drug (Formulary) Guide or call 800-537-9384.
  • Drugs not on the formulary. Formularies are developed and reviewed by the CVS Caremark Pharmacy and Therapeutics Committee, comprised of physicians, pharmacists and other clinicians that review drugs for inclusion in the formulary. They consider the drugs effectiveness and safety in their evaluation. While most of the drugs on the non-formulary list are brand drugs, some generic drugs also may be on the non-formulary list. For example, this may happen when brand medications lose their patent and the FDA has granted a period of exclusivity to specific generic manufacturers. When this occurs, the price of the generic drug may not decrease as you might think most generic drugs do. This period of exclusivity usually ranges between 3-6 months. Once this time period expires, competition from other generic manufacturers will generally occur and this helps lower the price of the drug and this may lead the Plan to re-evaluate the generic for possible inclusion on the formulary. We will place some of these generic drugs that are granted a period of exclusivity on our non-formulary list, which requires the highest copay level. Remember, a generic equivalent will be dispensed, if available, unless your physician specifically requires a brand name and writes "Dispense as Written" (DAW) on the prescription, so discuss this with your doctor.
  • Choose generics. The Plan requires the use of generics if a generic drug is available. If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance* unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained from the plan. 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, you will see cost savings, without jeopardizing clinical outcome or compromising quality. * The differential/penalty will not apply to Plan accumulators. (example: out-of-pocket maximum)
  • Precertification. Your pharmacy benefits plan includes precertification. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-approved 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 precertification for a drug. Step-therapy is another type of precertification. Certain medications will be excluded from coverage unless you try one or more "step" drug(s) first, or unless a medical exception is obtained. The drugs requiring precertification or step-therapy are subject to change. Visit our website at www.aetnafeds.com for the most current information regarding the precertification and step-therapy lists. Ask your physician if the drugs being prescribed for you require precertification or step therapy.



  • These are the dispensing limitations. Prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy may be covered 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.

    In the event that a member is called to active military duty and requires coverage under their prescription plan 
    benefits of an additional filing of their medication(s) prior to departure, their pharmacist will need to contact us.
    Coverage of additional prescriptions will only be allowed if there are refills remaining on the member's current 
    prescription or a new prescription has been issued by their physician.  The member is responsible for the applicable 
    copayment for the additional prescription.

  • The Plan allows coverage of a medication refill when at least 80% of the previous prescription, according to the physician’s prescribed directions, has been utilized. For a 30-day supply of medication, this provision would allow a prescription refill to be covered 24 days after the last filling, thereby allowing a member to have an additional supply of their medication, in case of emergency.
  • When you do have to file a claim. Send your itemized bill(s) to: Aetna, Pharmacy Management, P.O. Box 52444, Phoenix, AZ 85072-2444.



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.
  • Mail order pharmacy. Generally, the drugs available through mail order are maintenance drugs that you take on a regular basis for a chronic or long-term medical condition. Outpatient prescription drugs are covered when dispensed by a network mail order pharmacy or a CVS pharmacy®. Each prescription is limited to a maximum 90-day supply. Prescriptions for less than a 30-day supply or more than a 90-day supply are not eligible for coverage when dispensed by a network mail order pharmacy.
  • Specialty drugs. Specialty drugs are medications that treat complex, chronic diseases which includes select oral, injectable and infused medications. The first fill, including all subsequent refills must be obtained through a network specialty pharmacy. 

    Certain Specialty Formulary medications identified on the Specialty Drug List may be covered under the medical or pharmacy section of this brochure depending on how and where the medication is administered. If the provider supplies and administers the medication during an office visit, you will pay the applicable PCP or specialist office visit copay. If you obtain the prescribed medications directly from a network specialty pharmacy.  You will pay the applicable copay as outlined in Section 5(f) of this brochure.

    Often these drugs require special handling, storage and shipping. For a detailed listing of specialty medications visit www.aetnafeds.com/pharmacy or contact us at 800-537-9384 for a copy. Note that the medications and categories covered are subject to change. Some specialty medications may qualify for third-party copayment assistance programs that could lower your out of-pocket costs for those products. For any such specialty medication where third-party copayment assistance is used, you shall not receive credit toward your out-of-pocket maximum or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate.
  • To request a printed copy of the 2021 Pharmacy Drug (Formulary) Guide, call 800-537-9384. The information in the 2021 Pharmacy Drug (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.aetnafeds.com for current (Formulary) Guide information.



Benefit Description : Covered medications and suppliesHigh Option (You pay )

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

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

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

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

$10 per covered generic formulary drug;

$35 per covered brand name formulary drug; and

$100 per covered non-formulary (generic or brand name) drug.

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

$20 per covered generic formulary drug;

$70 per covered brand name formulary drug; and

$200 per covered non-formulary (generic or brand name) drug.

Women's contraceptive drugs and devices

  • Generic oral contraceptives on our formulary list
  • Generic injectable contraceptives on our formulary list - five (5) vials per calendar year
  • Generic emergency contraception, including OTC when filled with a prescription  
  • Diaphragms - one (1) per calendar year
  • Brand name Intra Uterine Device
  • Generic patch contraception
Nothing
  • Brand name contraceptive drugs
  • Brand name injectable contraceptive drugs such as Depo Provera - five (5) vials per calendar year
  • Brand emergency contraception 

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

$35 per covered brand name formulary drug; and

$100 per covered non-formulary (generic or brand name) drug.

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

$70 per covered brand name formulary drug; and

$200 per covered non-formulary (generic or brand name) drug.

Specialty Medications

Specialty medications must be filled through a network specialty pharmacy. These medications are not available through the mail order benefit.

Certain Specialty Formulary medications identified on the Specialty Drug List may be covered under the medical or pharmacy section of this brochure. Please refer to page 64, Specialty Drugs for more information or visit: www.aetnafeds.com/pharmacy.

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

Preferred: 50% up to $350 maximum

Non-preferred: 50% up to $700 maximum

Limited benefits:

  • Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period. Contact the Plan at 800-537-9384 for dose limits. Note: Mail order is not available.

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

$10 per covered generic formulary drug;

$35 per covered brand name formulary drug; and

$100 per covered non-formulary (generic or brand name) drug.

Benefit Description : Preventive care medicationsHigh Option (You pay )

Preventive Care medications to promote better health as recommended by ACA.

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

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

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

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

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

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

Nothing

Not covered:

  • Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law or covered by the plan
  • Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
  • Vitamins, unless otherwise stated (including prescription vitamins), nutritional supplements not listed as a covered benefit, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition except for nutritional formulas for the treatment of phenylketonuria branched chain ketonuria, galactosemia and homocystinuria when administered under the direction of a Plan doctor (please see Durable Medical Equipment section on page 40).
  • Medical supplies such as dressings and antiseptics
  • Drugs for cosmetic purposes
  • Lost, stolen or damaged drugs
  • Drugs to enhance athletic performance
  • Fertility drugs
  • Drugs used for the purpose of weight reduction, (i.e., appetite suppressants)
  • Prophylactic drugs including, but no limited to, anti-malarials for travel
  • Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
  • Compounded thyroid hormone therapy

Note: Over-the-counter (OTC) and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See page 42). Over-the-counter (OTC) drugs will not be covered unless you have a prescription and that prescription is presented at the pharmacy and processed through our pharmacy claim system.

All charges



Section 5(g). Dental Benefits

Important things you should keep in mind about these benefits:

  • You have two different dental options, Advantage Dental or Dental PPO, from which to choose. New members are automatically enrolled in the Advantage Dental option. If you want to switch to the Dental PPO option, you must call on or before the 15th of the month to have your coverage in the Dental PPO option be effective on the first of the following month (i.e., call on 1/8 and your coverage is effective on 2/1, but if you call on 1/17, your coverage will not be effective until 3/1).
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
  • Under the Advantage Dental option, you must select a Plan primary care dentist before receiving care. Your selected Plan primary care dentist must provide or arrange covered care. Services rendered by non-Plan dentists are not covered. The Plan will cover 100% of the charges for the preventive, diagnostic and restorative procedures shown on the next page. You will be responsible for a copayment of $5 for each office visit regardless of the number of procedures performed.
  • Note: You will be covered automatically under the Advantage Dental option unless you enroll in the Dental PPO option by calling Member Services at 800-537-9384.
  • Under the Dental PPO option, the Plan covers 100% of the charges (after satisfaction of a $20 annual deductible per member) for those preventive, diagnostic, and restorative procedures shown on the next page when using a participating network dentist. Participating network PPO dentists may offer members other services at discounted fees. Discounts may not be available in all states. Providers are not required to honor the contracted rate/discount for dental services that are not covered or not listed on the following page.
  • You also have the choice to use non-network dentists under this Dental PPO option for those preventive, diagnostic and restorative procedures shown on the next page, but the Plan will cover only 50% of the standard negotiated rate we would have paid an in-network PPO provider. You are responsible for any difference between the amount billed and the amount paid by the Plan for the eligible services listed in this section, plus your annual $20 deductible. Any other dental services rendered by non-network dentists are not covered.
  • 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 on the next pages.
  • 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.



Dental Benefits : Accidental injury benefitHigh Option (You Pay)

Coverage is limited to palliative treatment and those services listed on the following schedule.

Note: See Oral and maxillofacial surgery, section 5(b).

See benefits below



 

 

 

 

                                                                                                                                           

                                                                                                                                               Dental benefits begin on next page




Dental Benefits : ServiceAdvantage Dental (You Pay After the calendar year deductible...)PPO-Network (You Pay After the calendar year deductible...)PPO Non-Network (You Pay After the calendar year deductible...)

Annual Deductible

No Deductible$20 per member per year.   $20 per member per year.

Diagnostic

Office visit for routine oral evaluation — limited to 2 visits per year

Bitewing X-rays — limited to 2 sets of bitewing X-rays per year

Complete X-ray series — limited to 1 complete x-ray series in any 3 year period

Periapical X-rays and other dental X-rays — as necessary

Diagnostic casts

Preventive

Prophylaxis (cleaning of teeth) — limited to 2 treatments per year

Topical application of fluoride — limited to 2 courses of treatment per year to children under age 18

Oral hygiene instruction (not covered under PPO)

Restorative (Fillings)

Amalgam/Composite 1 surface, primary or permanent

Amalgam/Composite 2 surfaces, primary or permanent

Amalgam/Composite 3 surfaces, primary or permanent

Amalgam/Composite or more surfaces, primary or permanent

Prosthodontics Removable

Denture adjustments (complete or partial/upper or lower)

Endodontics

Pulp cap — direct

Pulp cap — indirect

Note:  Members can take advantage of our network discounts on other dental procedures when using participating network dentists for services.

No Deductible

$5 per visit

Nothing50% of our negotiated rate and any difference between our allowance and the billed amount.



Advantage Dental Option

Note: Advantage Dental option services shown in this section are only covered when provided by your selected participating primary care dentist in accordance with the terms of your Plan. If rendered by a participating specialist, they are provided at reduced fees. Pediatric dentists are considered specialists. Certain other services will be provided by your selected participating primary care dentist at reduced fees. Specific fees vary by area of the country. Call Member Services at 800-537-9384 for specific fees for your procedure. All member fees must be paid directly to the participating dentist. Services provided by a non-network dentist are not covered.

Each employee and dependent(s) automatically will be enrolled in the Advantage Dental option, unless you enroll in the Dental PPO option.

Each employee and dependent must select a primary care dentist from the directory when participating in the Advantage Dental option and include the dentist’s name on the enrollment form. You also may call Member Services at 800-537-9384.

Dental PPO Option

Under this option, you have the choice to use our participating Dental PPO network dentists or a non-network dentist. The benefit levels are different, based on whether or not the dentist participates in our network. You must contact Member Services at 800-537-9384 to select this option.

If you call on or before the 15th of the month, your coverage in the Dental PPO option will be effective on the first of the following month (i.e., call on 1/8 and your coverage is effective on 2/1, but if you call on 1/17, your coverage will not be effective until 3/1).

If you decide to switch back to the Advantage Dental Option, you must call Member Services at 800-537-9384. The same timing rules apply. You must also select a Primary Care Dentist. Your prior Primary Care Dentist will not be reassigned to you, unless you specifically request it.

Dental PPO In-Network Option

The plan covers 100% of the charges (after satisfaction of the $20 annual deductible per member) for those preventive, diagnostic, and restorative procedures shown on the previous page when using a participating network dentist. Participating network PPO dentists may offer members others services at discounted fees. Please call Member Services at 800-537-9384 for specific fees for your procedure.

Dental PPO Non-Network Option

Dentists’ normal fees generally are higher than Aetna’s negotiated fees. Non-participating dentists will be paid only for those services shown on the previous page. Payment will be based on the standard negotiated rate provided to participating general dentists in the same geographic area. Members may be able to take advantage of discounts when using network dentists. Discounts may not be available in all states.




Section 5(h). Wellness and Other Special Features (High Option)

TermDefinition
Flexible benefits option

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

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

Aetna Member Website

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

With Aetna Member Website, you can:

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

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

Services for deaf and hearing-impaired

800-628-3323




                                                                                                                                    Special features-continued on next page



TermDefinition

Informed Health® Line

Provides eligible members with phone 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 800-556-1555. We provide TDD service for the hearing and speech-impaired. We also offer foreign language translation for non-English speaking members. Informed Health Line nurses cannot diagnose, prescribe medication or give medical advice.

Maternity Management Program

Aetna’s Beginning Right®Maternity Management Program provides services, information and resources to help improve high risk 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 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.  Contact Member Services at 800-537-9384 for more information.

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 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.



Non-FEHB Benefits Available to Plan Members

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information, contact the plan at 888-238-6240 or visit their website at www.aetnafeds.com.

Vision Discounts

At Aetna, you get discounts on eyeglass frames from budget to designer brands, non-disposable contact lenses, the latest in lens technology, sunglasses, and more. With these built in discounts you’ll also see savings on LASIK laser eye surgery and popular lens options. You can visit many doctors in private practice. Plus, national chains like LensCrafters®, Target Optical®, and Pearle Vision®. You can find them all on your member website at aetnafeds.com.

Hearing Discounts

The hearing discounts can help you and your covered family members save on hearing exams, a large choice of leading brand hearing aids, batteries and free routine follow-up services. There are two ways for you to save at thousands of locations through Hearing Care Solutions or Amplifon Hearing Health Care. Visit your member website at aetnafeds.com for more information once you are a member.

Healthy lifestyle discounts

Save on gym memberships, health coaching, fitness gear and nutrition products that support a healthy lifestyle. You get access to local and national discounts on brands you know. At-home weight-loss programs with tips and menus; track progress from the privacy of your home. You can also save on wearable fitness devices, meditation, yoga, wellness programs and oral health care products. (Through our partnership with LifeMart®, you can also save on thousands of products and services, including health and wellness products, tickets, car rentals and coupons).

Natural products and services discount

Save on natural products and services. Enjoy these services* at a discount off the normal fee.  Ease your stress and tension with therapeutic massage.  Heal pain or stress points with acupuncture or chiropractic care.**  Get advice from registered dietitians with nutrition services. Visit your member website at aetnafeds.com for more information once you are a member.

* The ChooseHealthy® program is provided by ChooseHealthy, Inc., a subsidiary of American Specialty Health Incorporated (ASH). ChooseHealthy is a federally registered trademark of ASH and used with permission here in.
**Discounts do not apply to visits/claims submitted to your health insurance plan.

Once you’re a member, for full details on these discount programs and more, log in to your member website at aetnafeds.com and select the “Stay Healthy” tab.  

Discount offers may be available but are not guaranteed under our contract with the FEHB program. Please see                      www.aetnafeds.com for details.

Discount offers are not offers of insurance. They are not benefits under your health plan. You receive access to discounts off the regular charge on products and services offered by third-party vendors and providers. Aetna makes no payment to the third parties; you are responsible for the full cost. Check any health plan benefits you have before using these discount offers, as those benefits may give you lower costs than these discounts. Vendors and providers are not agents of Aetna and are solely responsible for the products and services they provide. Discount offers are not guaranteed and may be ended at any time. Aetna may get a fee when you buy these discounted products and services. Vision care providers are contracted through EyeMed Vision Care. LASIK surgery discounts are offered by the U.S. Laser Network and QualSight. Hearing products and services are provided by Hearing Care Solutions and Amplifon Hearing Health Care.




Section 6. General Exclusions – Services, Drugs and Supplies We Do Not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 When you need prior Plan approval for certain services.

We do not cover the following:

  • Care by non-Plan providers except for authorized referrals or emergencies (see Emergency services/accidents).
  • Services, drugs, or supplies you receive while you are not enrolled in this Plan.
  • Services, drugs, or supplies not medically necessary.
  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
  • Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants).
  • Procedures, services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
  • Services, drugs, or supplies you receive without charge while in active military service.
  • Cost of data collection and record keeping for clinical trials that would not be required, but for the clinical trial.
  • Items and services provided by clinical trial sponsor without charge.
  • Care for conditions that state or local law requires to be treated in a public facility, including but not limited to, mental illness commitments.
  • Court ordered services, or those required by court order as a condition of parole or probation, except when medically necessary.
  • Educational services for treatment of behavioral disorders.
  • Services provided by a family member or resident in the member’s home.
  • Services or supplies we are prohibited from covering under the Federal law.



Section 7. Filing a Claim for Covered Services

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received).  See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures.  When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these providers bill us directly. Check with the provider.

If you need to file the claim, here is the process:




TermDefinition

Medical, hospital and prescription drug benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB- 04 form. For claims questions and assistance, contact us at 800-537-9384, or at our website at www.aetnafeds.com.

When you must file a claim – such as for services you receive outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

  • Covered member’s name, date of birth, address, phone number and ID number
  • Name and address of the provider or facility that provided the service or supply
  • Dates you received the services or supplies
  • Diagnosis
  • Type of each service or supply
  • The charge for each service or supply
  • A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
  • Receipts, if you paid for your services

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

Submit your medical, hospital and vision claims to: Aetna, P.O. Box 14079, Lexington, KY 40512-4079.

Submit your dental claims to: Aetna, P.O. Box 14094, Lexington, KY 40512-4094.

Submit your pharmacy claims to: Aetna, Pharmacy Management, P.O. Box 52444, Phoenix, AZ 85072-2444.

Deadline for filing your claim

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

Post-service claims procedures

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

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

If you do not agree without initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Authorized RepresentativeYou may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, a health care professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent.  For the purposes of this section, we are also referring to your authorized representative when we refer to you.
Notice Requirements

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

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




Section 8. The Disputed Claims Process

You may appeal to the U.S. Office of Personnel Management (OPM) if we do not follow the required claims process.  For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Section 3, 7, and 8 of this brochure, please call Aetna's Customer Service at the phone number found on your ID card, plan brochure or plan website: www.aetnafeds.com.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admission.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Customer Service Department by writing Aetna, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512 or calling 800-537-9384.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or his/her subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.




StepDescription
1

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

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

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

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

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

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

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

2

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

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

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

3

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

4

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

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

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

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




 

 




Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-537-9384.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM's FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues.  For example, we do not determine whether you or a dependent is covered under this plan.  You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage

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

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

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

For example, we generally only make up the difference between the primary payor's benefit payment and 100% of our Plan allowance, subject to your applicable deductible, if any, and coinsurance or copayment amounts.

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

TRICARE and CHAMPVA

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

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

Workers' Compensation

We do not cover services that:

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

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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

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

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

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

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

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

This Plan always pays secondary to:

  • Any medical payment, PIP or No-Fault coverage under any automobile policy available to you.
  • Any plan or program which is required by law. You should review your automobile insurance policy to ensure that uncoordinated medical benefits have been chosen so that the automobile insurance policy is the primary payer.

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

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

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

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

a) The Workers’ Compensation benefits are in dispute or are paid by means of settlement or compromise;

b) No final determination is made that bodily injury or sickness was sustained in the course of or resulted from the member’s employment;

c) The amount of Workers’ Compensation benefits due to medical or health care is not agreed upon or defined by the member or the OWCP or other Workers’ Compensation carrier; or

d) The medical or health care benefits are specifically excluded from the Workers’ Compensation settlement or compromise.

By accepting benefits under this Plan, the member or the member’s representatives agree to notify Aetna of any Workers’ Compensation claim made, and to reimburse us as described above.

Aetna may exercise its recovery rights against the provider in the event:

a) the employer or carrier is found liable or responsible according to a final adjudication of the claim by the OWCP or other party responsible for adjudicating such claims; or

b) an order approving a settlement agreement is entered; or

c) the provider has previously been paid by the carrier directly, resulting in a duplicate payment.

Clinical trials

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

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

  • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s cancer, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan. See page 47.
  • Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs. See page 50.
  • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs. See page 50.

When you have Medicare

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

  • The Original Medicare Plan (Part A or Part B)

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

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-537-9384.

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

You can find more information about how our plan coordinates benefits with Medicare by calling 800-537-9384 or see our website www.aetnafeds.com.

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

Benefit Description: Deductible
High Option You pay without Medicare: $0
High Option You pay with Medicare Part A and B (primary): $0

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

Benefit Description: Primary Care Physician
High Option You pay without Medicare: $20 per visit
High Option You pay with Medicare Part A and B (primary): $20 per visit

Benefit Description: Specialist
High Option You pay without Medicare: $35 per visit
High Option You pay with Medicare Part A and B (primary): $35 per visit

Benefit Description: Inpatient Hospital
High Option You pay without Medicare: $250 per day up to $1,000 per admission
High Option You pay with Medicare Part A and B (primary): $250 per day up to $1,000 per admission

Benefit Description: Outpatient Hospital
High Option You pay without Medicare: $175 per visit
High Option You pay with Medicare Part A and B (primary): $175 per visit

Benefit Description: Incentives offered
High Option You pay without Medicare: N/A
High Option You pay with Medicare Part A and B (primary): We offer no additional incentives when a member has Medicare Part B.


You can find more information about how our plan coordinates benefits with Medicare by calling 800-537-9384.

Tell us about your Medicare coverage

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

Medicare Advantage (Part C)

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

To learn more about Medicare Advantage Plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage Plan: You may enroll in our Medicare Advantage Plan and also remain enrolled in our FEHB Plan. If you are an annuitant or former spouse with FEHBP coverage and are enrolled in Medicare Parts A and B, you may enroll in our Medicare Advantage Plan if one is available in your area. For more information, please call us at 888-788-0390. We do not waive cost-sharing for your FEHB coverage.

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

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

Medicare prescription drug coverage (Part D)

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




Primary Payer Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you the primary payer for the individual with Medicare is ...The Primary Payer for individual with Medicare is…The Primary Payer for individual is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • You have FEHB coverage on your own or through your spouse who is also an active employee
  • You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status
8) Are a Federal employee receiving Workers' Compensation disability benefits for six months or more


B. When you or a covered family member...The Primary Payer for individual with Medicare is…The Primary Payer for individual is this Plan
1) Have Medicare solely based on end stage renal disease(ESRD) and..
  • It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30 month coordination period)
  • It is beyond the 30 month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • This Plan was the primary payer before eligibility due to ESRD (for 30 month coordination period)
  • Medicare was the primary payer before eligibility due to ESRD
3) Have Temporary Continuation of Coverage(TCC) and...
  • Medicare based on age and disability
  • Medicare based on ESRD (for the 30 month coordination period)
  • Medicare based on ESRD (after the 30 month coordination period)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The Primary Payer for individual with Medicare is…The Primary Payer for individual is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers’ Compensation is primary for claims related to your condition under Workers’ Compensation.




Section 10. Definitions of Terms We Use in This Brochure

TermDefinition
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical Trials Cost Categories

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

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

  • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this Plan.  See page 47.
  • Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs.  See page 50.
  • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.  See page 50.

Coinsurance

See Section 4, page 26.

Copayment

See Section 4, page 26.

Cost-sharing

See Section 4, page 26.

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

Deductible

See Section 4, page 26.

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

Experimental or investigational service

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

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

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

Health care professionalA physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

Medical necessity

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

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

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

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

Open Access HMOThis does not apply to the State of California (Enrollment Code 2X). You can go directly to any network specialist for covered services without a referral from your primary care physician .  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).  While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan.  If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.
Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for the service or supply in the geographic area where it is furnished. Plans determine their allowances in different ways. We determine our allowance as follows: We may take into account factors such as the complexity, degree of skill needed, type or specialty of the provider, range of services provided by a facility, and the prevailing charge in other areas in determining the Plan allowance for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of providers in the area.
Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims were treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
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 you. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments.

Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services.
Preventive care Health care services designed for prevention and early detection of illnesses in average risk people, generally including routine physical examinations, tests and immunizations.
Referral

For California members only: To receive coverage for any non-emergency service and necessary follow-up care outside those provided by your PCP, the member must have a written or electronic referral made by the PCP or no coverage will be provided (with the exception of some direct access providers within the network).

For Open Access members, you do not need a referral for specialist care within our network.

ReimbursementA carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
Respite care Care furnished during a period of time when your family or usual caretaker cannot, or will not, attend to your needs. Respite care is not covered.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.
Urgent care Covered benefits required in order to prevent serious deterioration of your health that results from an unforeseen illness or injury if you are temporarily absent from our service area and receipt of the health care service cannot be delayed until your return to our service area.

Urgent care claims

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department at 800-537-9384.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us/We Us and We refer to Aetna.
You You refers to the enrollee and each covered family member.



Notes

TermDefinition
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical Trials Cost Categories

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

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

  • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this Plan.  See page 47.
  • Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs.  See page 50.
  • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.  See page 50.

Coinsurance

See Section 4, page 26.

Copayment

See Section 4, page 26.

Cost-sharing

See Section 4, page 26.

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

Deductible

See Section 4, page 26.

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

Experimental or investigational service

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

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

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

Health care professionalA physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

Medical necessity

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

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

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

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

Open Access HMOThis does not apply to the State of California (Enrollment Code 2X). You can go directly to any network specialist for covered services without a referral from your primary care physician .  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).  While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan.  If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.
Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for the service or supply in the geographic area where it is furnished. Plans determine their allowances in different ways. We determine our allowance as follows: We may take into account factors such as the complexity, degree of skill needed, type or specialty of the provider, range of services provided by a facility, and the prevailing charge in other areas in determining the Plan allowance for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of providers in the area.
Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims were treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
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 you. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments.

Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services.
Preventive care Health care services designed for prevention and early detection of illnesses in average risk people, generally including routine physical examinations, tests and immunizations.
Referral

For California members only: To receive coverage for any non-emergency service and necessary follow-up care outside those provided by your PCP, the member must have a written or electronic referral made by the PCP or no coverage will be provided (with the exception of some direct access providers within the network).

For Open Access members, you do not need a referral for specialist care within our network.

ReimbursementA carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
Respite care Care furnished during a period of time when your family or usual caretaker cannot, or will not, attend to your needs. Respite care is not covered.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.
Urgent care Covered benefits required in order to prevent serious deterioration of your health that results from an unforeseen illness or injury if you are temporarily absent from our service area and receipt of the health care service cannot be delayed until your return to our service area.

Urgent care claims

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department at 800-537-9384.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us/We Us and We refer to Aetna.
You You refers to the enrollee and each covered family member.



TermDefinition
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical Trials Cost Categories

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

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

  • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this Plan.  See page 47.
  • Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs.  See page 50.
  • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.  See page 50.

Coinsurance

See Section 4, page 26.

Copayment

See Section 4, page 26.

Cost-sharing

See Section 4, page 26.

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

Deductible

See Section 4, page 26.

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

Experimental or investigational service

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

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

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

Health care professionalA physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

Medical necessity

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

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

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

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

Open Access HMOThis does not apply to the State of California (Enrollment Code 2X). You can go directly to any network specialist for covered services without a referral from your primary care physician .  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).  While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan.  If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.
Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for the service or supply in the geographic area where it is furnished. Plans determine their allowances in different ways. We determine our allowance as follows: We may take into account factors such as the complexity, degree of skill needed, type or specialty of the provider, range of services provided by a facility, and the prevailing charge in other areas in determining the Plan allowance for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of providers in the area.
Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims were treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
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 you. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments.

Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services.
Preventive care Health care services designed for prevention and early detection of illnesses in average risk people, generally including routine physical examinations, tests and immunizations.
Referral

For California members only: To receive coverage for any non-emergency service and necessary follow-up care outside those provided by your PCP, the member must have a written or electronic referral made by the PCP or no coverage will be provided (with the exception of some direct access providers within the network).

For Open Access members, you do not need a referral for specialist care within our network.

ReimbursementA carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
Respite care Care furnished during a period of time when your family or usual caretaker cannot, or will not, attend to your needs. Respite care is not covered.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.
Urgent care Covered benefits required in order to prevent serious deterioration of your health that results from an unforeseen illness or injury if you are temporarily absent from our service area and receipt of the health care service cannot be delayed until your return to our service area.

Urgent care claims

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department at 800-537-9384.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us/We Us and We refer to Aetna.
You You refers to the enrollee and each covered family member.



Index

Do not rely only on this page; it is for your convenience and may not show all pages where the terms appear.



Index Entry
(Page numbers solely appear in the printed brochure)
Accidental injury
Allergy tests
Allogeneic transplants
Alternative treatments
Ambulance
Anesthesia
Autologous bone marrow transplant
Bariatric surgery
Biopsy
Blood and blood plasma
Casts
Catastrophic protection out-of-pocket maximum
Changes for 2021
Chemotherapy
Chiropractic
Cholesterol tests
Claims
Coinsurance
Colorectal cancer screening
Congenital anomalies
Contraceptive drugs and devices
Cost-sharing
Covered charges
Crutches
Deductible
Definitions
Dental care
Diagnostic services
Donor expenses
Durable medical equipment
Effective date of enrollment
Emergency
Experimental or investigational
Eyeglasses
Family planning
Fecal occult blood test
Fraud
General exclusions
Hearing services
Home health services
Hospital
Immunizations
Infertility
Inpatient hospital benefits
Insulin
Magnetic Resonance Imagings (MRIs)
Mammogram
Maternity benefits
Medicaid
Medically necessary
Medicare
Medicare Advantage
Original
Mental Health/Substance Misuse benefits
Newborn care
Non-FEHB benefits
Nurse
Occupational therapy
Office visits
Open Access
Oral and maxillofacial surgical
Orthopedic devices
Out-of-pocket expenses
Oxygen
Pap test
Physical therapy
Physician
Precertification
Prescription drugs
Preventive care, adult
Preventive care, children
Preventive services
Prosthetic devices
Psychologist
Radiation therapy
Room and board
Second surgical opinion
Skilled nursing facility care
Smoking cessation
Social worker
Speech therapy
Splints
Subrogation
Substance misuse
Surgery
Anesthesia
Outpatient
Reconstructive
Syringes
Temporary Continuation of Coverage (TCC)
Transplants
Treatment therapies
Urgent care
Vision care
Wheelchairs
Workers' Compensation
X-ray



Summary of Benefits for the High Option of the Aetna Open Access Plan - 2021

  • Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.aetnafeds.com
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.



TermDefinition 1Definition 2

Medical services provided by physicians: Diagnostic and treatment services provided in the office

Office visit copay: $20 primary care; $35 specialist

31

Services provided by a hospital: Inpatient

$250 per day up to a maximum of $1,000 per admission

52

Services provided by a hospital: Outpatient

$175 per visit

53

Emergency benefits: In-area

$125 per visit

57

Emergency benefits: Out-of-area

$125 per visit

57

Mental health and substance use disorder treatment:

Regular cost-sharing

59

Prescription drugs: In no event will the copay exceed the cost of the prescription drug. Retail Pharmacy: For up to a 30-day supply per prescription unit or refill

$10 copay per generic formulary drug;

$35 copay per brand name formulary drug; and

$100 copay per non-formulary drug (generic or brand name).

64

Prescription drugs: In no event will the copay exceed the cost of the prescription drug. Mail Order Pharmacy: For a 31-day up to a 90-day supply per prescription unit or refill

$20 copay per generic formulary drug;

$70 copay per brand name formulary drug; and

$200 copay per non-formulary drug (generic or brand name).

64

Specialty Medications:  For up to a 30-day supply per prescription unit or refill

Preferred: 50% up to a $350 maximum per prescription
Non-preferred: 50% up to $700 maximum per prescription

65

Dental care:

Various copays, coinsurance, reduced fees or deductibles

68

Vision care:

$35 copay per visit. All charges over $100 for eyeglasses or contacts per 24-month period

38

Special features: Flexible benefits option, Aetna Member Website, Services for the deaf and hearing-impaired, Informed Health Line, Maternity Management Program, National Medical Excellence Program, and Reciprocity benefit.

Contact Plan at 800-537-9384

71

Protection against catastrophic costs (out-of-pocket maximum):

Nothing after $5,000/Self Only enrollment or $10,000/Self Plus One or Self and Family enrollment per year.

Some costs do not count toward this protection.

26




2021 Rate Information for the Aetna Open Access Plan

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

Postal rates apply to certain United States Postal Service employees as follows:

  • Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreement: NALC.
  • Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement: PPOA.

Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career bargaining unit employees who are represented by the following agreements: APWU, IT/AS, NPMHU, NPPN and NRLCA. Postal rates do not apply to non-career Postal employees, Postal retirees, and associate members of any Postal employee organization who are not career Postal employees.

If you are a Postal Service employee and have questions or require assistance, please contact:

USPS Human Resources Shared Service Center: 1-877-477-3273, option 5, Federal Relay Service 1-800-877-8339

Premiums for Tribal employees are shown under the monthly non-Postal column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.




Phoenix and Tucson Areas, Arizona
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
High Option Self OnlyWQ1$241.58$379.50$523.42$822.25$376.14$366.08
High Option Self Plus OneWQ3$517.46$975.55$1,121.16$2,113.70$968.36$946.80
High Option Self and FamilyWQ2$562.25$945.71$1,218.21$2,049.04$937.90$914.48
Los Angeles and San Diego Areas, California
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
High Option Self Only2X1$241.58$190.73$523.42$413.25$187.37$177.31
High Option Self Plus One2X3$517.46$477.57$1,121.16$1,034.74$470.38$448.82
High Option Self and Family2X2$562.25$452.68$1,218.21$980.81$444.87$421.45
Pittsburgh and Western PA Areas, Pennsylvania
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
High Option Self OnlyYE1$241.58$315.29$523.42$683.13$311.93$301.87
High Option Self Plus OneYE3$517.46$866.99$1,121.16$1,878.48$859.80$838.24
High Option Self and FamilyYE2$562.25$836.04$1,218.21$1,811.42$828.23$804.81
Atlanta and Athens Areas, Georgia
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
High Option Self Only2U1$241.58$591.89$523.42$1,282.43$588.53$578.47
High Option Self Plus One2U3$517.46$1,383.40$1,121.16$2,997.37$1,376.21$1,354.65
High Option Self and Family2U2$562.25$1,357.62$1,218.21$2,941.51$1,349.81$1,326.39