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

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

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

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

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

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

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

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

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

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

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status including your marriage, divorce, annulment or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

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

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

Family members covered under your Self and Family enrollment are your spouse (including your spouse by 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 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.

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2027 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 2026 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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

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

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

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

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member 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: https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health.  We may request that you verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

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

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

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

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

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

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

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

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

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

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

This HMO Plan is available to our members in those FEHBP service areas identified starting in Section 1. You need a referral from your primary care provider to see Specialists. Whether your covered services are provided by your selected primary care provider (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). You are required to select a PCP and notify Member Services of your selection (800-537-9384). 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.

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.

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.  

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law.  We credential Plan providers according to national standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

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.

Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

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

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.

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

It depends on the type of care you need. First, you and each family member should choose a primary care provider. This decision is important since your primary care provider 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.

Your primary care provider can be a general practitioner, family practitioner, internist or pediatrician. Your primary care provider will provide or coordinate most of your health care.

If you want to change primary care providers or if your primary care provider leaves the Plan, call us or visit our website. We will help you select a new one.

Your primary care provider will refer you to a specialist for needed care. If you need laboratory, radiological and physical therapy services, your primary care provider must refer you to certain plan providers. Your primary care provider may refer you to any participating specialist for other specialty care. If your primary care provider is part of an IPA, you will be referred to IPA-approved specialists. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals. The primary care provider must provide or authorize follow-up care. Do not go to the specialist for return visits unless your primary care provider 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:

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care provider will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
• Your primary care provider 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 provider. If they decide 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 provider, 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.
• You may continue seeing your specialist for up to 90 days if you are undergoing treatment for a chronic or disabling condition and you lose access to your specialist because:
  • we terminate our contract with your specialist for other than cause
  • we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
  • we 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.

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

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

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

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

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

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

Your primary care provider 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)
• Ankle arthroplasty (total)
• Arthroscopic hip surgery to repair impingement syndrome, including labral repair*
• Autologous chondrocyte implantation
• Cardiology (implantable loop recorder, Watchman™, Electrophysiological (EP) study)
• 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
• Durable Medical Equipment, such as:
  • Electric or motorized wheelchairs and scooters
  • Prosthetics - Lower Limb
  • Stimulators
• Endoscopic nasal balloon dilation procedures
• Functional endoscopic sinus surgery
• Hip Osteotomy
• Hip surgery to repair impingement syndrome
• Hyperbaric oxygen therapy
• Hyperthermic intraperitoneal chemotherapy (HIPEC)
• Infertility services and pre-implantation genetic testing
• Knee arthroscopy and meniscectomy
• Lower limb prosthetics, such as: Microprocessor controlled lower limb prosthetics
• Neurostimulator implantation
• 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)
• Prostate surgery (high intensity-focused ultrasound)
• Proton beam radiotherapy
• Reconstructive or other procedures that may be considered cosmetic, such as:
  • Blepharoplasty
  • Breast reconstruction/breast enlargement
  • Breast reduction/mammoplasty
  • Excision of excessive skin due to weight loss
  • Gastroplasty/gastric bypass
  • Lipectomy or excess fat removal
  • Surgery for varicose veins, except stab phlebectomy
• Shoulder arthroplasty
• Site of Service - when requested at an Outpatient hospital setting and when is one of the following:
  • Breast tissue excision
  • Complex wound repair
  • Cystourethroscopy
  • Tenodesis of long tendon of biceps
  • Septoplasty
  • Skin tissue transfer or rearrangement
  • Turbinate resection
• Spinal procedures, such as:
  • Artificial intervertebral disc surgery (cervical and lumbar spine)
  • Cervical laminoplasty
  • Cervical, lumbar and thoracic laminectomy/laminotomy procedures
  • Kyphectomy
  • Laminectomy with rhizotomy
  • Removal of spinal instrumentation
  • Sacroiliac joint fusions
  • Spinal fusion surgery
  • Surgery for spinal deformity
  • Vertebral corpectomy
  • Vertebroplasty/Kyphoplasty
• Stimulators (electrical stimulation device used for cancer treatment)
• Urology-Artificial urinary sphincter
• Uvulopalatopharyngoplasty, including laser-assisted procedures
• Ventricular assist devices
• Whole exome sequencing
• Whole genome 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, Home Health Care, National Medical Excellence Program®, Pain management, Peripheral Arterial Disease, Polysomnography (attended sleep studies), Radiation oncology, Radiology imaging (such as CT scans, MRIs, MRAs, nuclear stress tests)*

Some services require prior approval or precertification before we will consider them for benefits. Your Network physician will take care of obtaining prior approval. Call us at 800-537-9384 as soon as the need for these services is determined.

*For a complete list refer to:
www.Aetna.com/Health-Care-Professionals/Precertification/Precertification-Lists.html or the Behavioral Health Precertification list. The specialty medication precertification list can be found at: www.AetnaFeds.com/Pharmacy.php.

Aetna works with providers to assist in determining the best setting for medical services to ensure safe, effective care at the right cost, covering infusion, injection, radiology, and specialized therapies. For more information, refer to: www.aetna.com/health-care-professionals/utilization-management/drug-infusion-site-of-care-policy.html

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.

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.

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).

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

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

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

You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than a total of three (3) days 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 hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

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

If 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.

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

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

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

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

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

  3.  Write to you and maintain our denial.

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

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

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

A 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 provider, you pay a copayment of $20 per office visit, or a copayment of $35 per office visit when you see a participating specialist.

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 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.

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

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). 
• Infertility services covered under the medical benefit 

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.

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.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.
A surprise bill is an unexpected bill you receive for:

• emergency care provided by nonparticipating providers – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services provided by certain nonparticipating providers at a participating health care facility,
• nonparticipating air ambulance services

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

Your health plan must comply with the NSA protections that hold you harmless from surprise bills. Any claims subject to the No Surprises Act will be paid in accordance with the requirements of such law.  Aetna will determine the rate payable to the out-of-network provider based on the median in-network rate or such other data resources or factors as determined by Aetna. Your cost share paid with respect to the items and services will be based on the qualifying payment amount, as defined under the No Surprises Act, and applied toward your in-network deductible (if you have one) and out-of-pocket maximum.

Please note: there are certain circumstances under the law where a provider can give you notice that they are out of network and you can consent to receiving a balance bill.  For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.aetnafeds.com or contact the health plan at 800-537-9384.

• Healthcare FSA (HCFSA) – Reimburses an FSA participant for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, over-the-counter drugs and medications, vision and dental expenses, and much more) for their tax dependents, and their 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.

Professional services of physicians

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

$20 per primary care provider (PCP) visit

$35 per specialist visit

• During a hospital stay
• In a skilled nursing facility

• In an urgent care center

• At home

$25 per PCP visit

$35 per specialist visit

• Walk-In Clinic

$25 per PCP visit

• Teladoc Health consult

• CVS Health Virtual Care™ consult

$0 per consult

Please see www.AetnaFeds.com/Tools.php for information on medical and behavioral telehealth services.

Members will receive a welcome kit explaining the telehealth benefits.

Refer to Section 5(e) for behavioral health telehealth consults.

Not applicable.

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 your physician performs and bills for the lab work; otherwise if lab work is performed by another physician or the specimen is sent to an independent lab.

$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 Section 3, “Other Services” under “You need prior Plan approval for certain services.” 

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

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

*Note: Requires precertification. See Section 3, “Other Services” under “You need prior Plan approval for certain services.” 

Nothing when authorized as preventive service.

• 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.

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Routine use of adult immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and adopted by the Centers for Disease Control and Prevention (CDC) are covered. A recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the CDC. For the current immunization schedule, visit https://www.cdc.gov/vaccines/imz-schedules/index.html
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at www.hrsa.gov/womens-guidelines
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy, limited to 26 visits per person per calendar year
• Counseling programs when medically identified to support obesity prevention and management by an in-network provider

Note: When anti-obesity medications are prescribed, see Section 5(f).

Note: When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity, see Section 5(b). 

Nothing

Routine mammogram 

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

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.

Not covered:

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

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org. For preventive immunizations see guidance below.
• Routine use of children’s immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) schedule and adopted by the Centers for Disease Control and Prevention (CDC) are covered. A recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the CDC. For the current
  immunization schedule, visit https://www.cdc.gov/vaccines/imz-schedules/index.html
• You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at www.uspreventiveservicestaskforce.org  
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

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.

• 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.

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to comprehensive, intensive nutrition and behavioral weight-loss therapy and counseling programs under the USPSTF A and B recommendations. These programs are covered as part of prevention and treatment of obesity as follows:

• Comprehensive, intensive nutrition and behavioral weight-loss counseling therapy.

Note: When anti-obesity medication is prescribed, see Section 5(f). 

Note: When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity, see Section 5(b). 

Nothing

Not covered:

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

All charges

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.
• Screening and counseling for prenatal and postpartum depression

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

• Amniocentesis
• Certain Pregnancy diagnostic lab tests
• Delivery including Anesthesia
• Fetal Stress Tests
• High Risk Specialist Visits
• Inpatient admissions
• Ultrasounds
• Screening for gestational diabetes
• Delivery
• Postnatal care

Notes:

• You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period.  To enroll in the Aetna Healthy Chapters^TM program, call toll-free 1-800-272-3531.
• 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 Only, 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.
• We pay hospitalization and surgeon services for maternity care (delivery) the same as for illness and injury.
• Hospital Services are covered in Section 5c and Surgery benefits are covered in Section 5b).

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

Note: Also see our Aetna Healthy Chapters^TM program in Section 5h.

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 and lactation support, supplies and counseling for each birth

Not covered:  Home births

All charges

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories in the HRSA supported guidelines.  This list includes: 

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

Note: See additional Family Planning and Prescription drug coverage in Section 5f.

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost.

Visit www.AetnaFeds.com/FamilyPlanning.php for more information on contraception and the exception process.

Once we have been contacted with exception request information sufficient for us to make a determination, you will receive a response within 24 hours or the next business day. Contraceptive exception requests are not subject to Section 8, The Disputed Claims Process.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

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

• Voluntary male sterilization (See Surgical procedures in Section 5b.)

$20 per PCP visit
$35 for Specialist visit

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Infertility is a disease defined as when a person is unable to conceive or produce conception after one year of egg-sperm contact when the individual attempting conception is under 35 years of age, or after six months of egg-sperm contact when the individual attempting conception is 35 years of age or older.  Egg-sperm contact can be achieved by regular sexual intercourse or artificial insemination (intrauterine, intracervical, or intravaginal) as stated in our medical clinical policy bulletin (see Section 10. for definition of Medical Necessity for additional details on Aetna’s Clinical Policy).  This definition applies to all individuals regardless of sexual orientation or the presence/availability of a reproductive partner.  Infertility may also be established by the demonstration of a disease or condition of the reproductive tract such that egg-sperm contact would be ineffective.

Diagnosis and treatment of infertility such as:

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

Artificial insemination (AI)* ** 

• Intravaginal insemination (IVI)
• Intracervical insemination (ICI)
• Intrauterine insemination (IUI)

$175 per visit 

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

Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See Section 4 for details)

Advanced Reproductive Technologies (ART):* **

(Combined limit of 3 cycles of Ovulation induction and In vitro fertilization (IVF) per calendar year).

• Ovulation induction 

• Egg retrieval and fertilization 

• Intracytoplasmic sperm injection (ICSI) 

• Embryo transfer  

We limit Ovulation Induction and In Vitro Fertilization (IVF) to 3 cycles per calendar year. The Plan defines a “cycle” as:

• Ovulation induction cycle(s) while on injectable medication (including but not limited to menotropins, hCG, GnRH) to stimulate the ovaries. *(See Section 5(f) for coverage)
• Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician *
• Injectable fertility drugs including but not limited to menotropins, hCG, and GnRH agonists. (See Section 5(f) for coverage)*

You are eligible for covered ovulation induction medication cycles if:

• You or your partner have been diagnosed with infertility.
• You have met the requirement for the number of months trying to conceive through egg and sperm contact.
• Your unmedicated day 3 Follicle Stimulating Hormone (FSH) level and testing of ovarian responsiveness meet the criteria outlined in Aetna’s infertility clinical policy

You are eligible for IVF if you meet our medical necessity criteria, which includes: 

• Natural or artificial insemination would not be expected to be effective, and ART would be expected to be the only effective treatment OR
• You have met the requirement for the number of months trying to conceive through egg and sperm contact (For women under 35 years of age, an appropriate trial of egg-sperm contact requires 12 months of regular intravaginal inseminations or 4 cycles of timed intrauterine or intracervical inseminations, documented in the medical record.  For women 35 years of age and older, an appropriate trial of egg-sperm contact requires 6 months of regular intravaginal inseminations or 3 cycles of timed intrauterine or intracervical insemination, documented in the medical record);
• You have met the requirement for trying to conceive through ovulation induction (3 cycles for women 37 years of age or younger); AND
• You or your partner have not gone through voluntary sterilization with or without reversal; AND
• Your unmedicated day three (3) Follicle Stimulating Hormone (FSH) level and testing of ovarian responsiveness meet the criteria outlined in Aetna’s Clinical Policy Bulletin (CPB) for Infertility.

Note: The Plan does not cover infertility drugs under the medical benefit. See Section 5(f) for coverage.

$175 per visit 

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

Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See Section 4 for details)

Iatrogenic Infertility* **

• Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing iatrogenic infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease.
• Storage of Embryo(s), Egg(s), Sperm for one year for members facing iatrogenic infertility. * **

Note: Storage costs are only covered for members who have undergone an approved fertility preservation procedure while covered under the Plan.

$175 per visit 

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

Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See Section 4 for details)

Aetna’s National Infertility Unit

Our NIU is here to help you and is staffed by a dedicated team of registered nurses and infertility coordinators. They can help you with understanding your benefits and the medical precertification process. You can learn more at www.AetnaInfertilityCare.com or call the NIU at 1-800-575-5999  (TTY: 711).

* Subject to medical necessity

** Note: Requires Precertification. See Section 3 “Other Services” under “You need prior Plan approval for certain services.”  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. Your network provider will request approval from us in advance for your infertility services. If your provider is not a network provider, you are responsible to request approval from us in advance.

Not applicable.

Not covered:

• All infertility services associated with or in support of an Advanced Reproductive Technology (ART) cycle (except for those medically necessary services as stated above). These include, but are not limited to:
  • Imaging, laboratory services, and professional services
  • In vitro fertilization (IVF)
  • Zygote intrafallopian transfer (ZIFT)
  • Gamete intrafallopian transfer (GIFT)
  • Cryopreserved embryo transfers
  • Gestational carrier cycles
  • Any related services, products or procedures (such as intracytoplasmic sperm injection (ICSI) or ovum microsurgery).
• Cryopreservation (freezing), storage or thawing of eggs, embryos, sperm or reproductive tissue (unless noted as covered)
• All charges associated with or in support of surrogacy arrangements for you or the surrogate. A surrogate is a female carrying her own genetically related child with the intention of the child being raised by someone else, including the biological father
• Any charges associated with care required to obtain ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc.); and any charges associated with obtaining sperm for ART procedures except as stated above
• 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. This includes tubal ligation, hysterectomy and vasectomy only if obtained as a form of voluntary sterilization
• 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. (unless stated above under iatrogenic infertility services)
• Cost of home ovulation predictor kits or home pregnancy kits
• Drugs related to the treatment of non-covered benefits
• Infertility services that are not reasonably likely to result in success
• Elective fertility preservation, such as egg freezing sought due to natural aging
• Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention (unless medical necessity is met for infertility benefits)
• Storage costs (except for one year of storage as noted in covered section of iatrogenic infertility) 
• Obtaining sperm from a person not covered under this plan
• Infertility treatment when a successful pregnancy could have been obtained through less costly treatment
• Infertility treatment when infertility is due to a natural physiologic process such as age related ovarian insufficiency (e.g. perimenopause, menopause) as measured by an unmedicated FSH level at or above 19 on cycle day two or three of your menstrual period or other abnormal testing results as outlined in Aetna’s infertility clinical policy
• Oral and Injectable infertility medication, see Section 5f
• Any infertility service rendered that requires precertification without a prior authorization
• Coverage for services received by a spouse or partner who is not a covered member under the plan

• 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

• 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 in Section 5(b).

• 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 800-537-9384 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 “Other Services” under “You need prior Plan approval for certain services” 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, then facility charges will apply. See Section 5(c) for applicable facility charges.

60 combined visits per person, per calendar year for physical or occupational therapy or a combination of both. 

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

• 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

• 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

• 60 visits per person, per calendar year

$35 per visit

Nothing during a covered inpatient admission

• Audiological testing and medically necessary treatment for hearing problems
• Hearing testing for children through age 17 (see Section 5(a) 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

• 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.

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

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

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

$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 (except for surgical treatment) 
• Foot orthotics
• Podiatric shoe inserts

• 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).

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

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• All charges over $500 for hair prosthesis

We cover rental or purchase of prescribed 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
• Medical foods taken for the treatment of Inborn Errors of Metabolism when provided by a participating DME provider and administered under the direction of a physician

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

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
• Medical foods that do not require a prescription under Federal law even if your physician or other health care professional prescribes them
• Nutritional supplements that are not administered by catheter or nasogastric tubes, except for oral medical foods taken for the treatment of Inborn Errors of Metabolism when administered under the direction of a physician
• Replacement of durable medical equipment, prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s condition.

• 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.

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

Not covered:

• Any services not listed above

Acupuncture - 20 visits per member per calendar year.

Note: See Section 5(b) 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

Aetna offers disease management. 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.

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.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Routine 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 severe 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

* Requires Precertification. See Section 3, “Other Services” under “You need prior Plan approval for certain services.” 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.

** Subject to medical necessity based on our clinical policy bulletin.

$20 per PCP visit

$35 per specialist visit

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

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 Section 5(a) Foot care)

• 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 Section 5(a) 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 (See Section 5(d) Accidental injury).
• Surgery for Sex-Trait Modification to treat gender dysphoria

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

These solid organ and tissue 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" in Section 3.

• 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 non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)*
  • Hemoglobinopathies
  • Hematopoietic Stem Cell Transplant (HSCT)
  • 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
  • Hematopoietic Stem Cell Transplant (HSCT)
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
  • Waldenstrom’s macroglobulinemia

*Approved clinical trial necessary for coverage.

$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.

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

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

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.

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.

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

• 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.

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

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 Section 3, “Other Services” under “You need prior Plan approval for certain services.” 

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

Not covered:

• Whole blood and concentrated red blood cells not replaced by the member

$5 copay

Aetna covers emergency transportation (ground, air or water) from the place of injury or illness to the first facility to provide emergency services.  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 facility to another if the first facility cannot provide the emergency services to treat the member; or
3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

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

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 services for routine transportation
• Ambulance service for non-emergency transportation except described above
• Ambulette service
• Ambulance transportation for member convenience or reasons that are not medically necessary
• Air and water ambulance transportation without prior approval

$20 per PCP visit

$35 per specialist visit

$150 per visit

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

All charges

$150 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

• Teladoc Health consult

• CVS Health Virtual Care™

$0 per consult

Please see www.aetnafeds.com/tools.php for information on medical and behavioral health telehealth services.

Members will receive a welcome kit explaining the telehealth benefits.

Refer to Section 5(e) for behavioral health telehealth consults.

Not applicable.

Aetna covers emergency transportation (ground, air or water) from the place of injury or illness to the first facility to provide emergency services.  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 facility to another if the first facility cannot provide the emergency services to treat the member; or

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

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

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

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 service for non-emergency transportation except described in Section 5(c).
• Ambulance transportation to receive outpatient or inpatient services and back home again, except in an emergency.
• Ambulette service.
• Air and water ambulance transportation without prior approval.
• Ambulance transportation for member convenience or for reasons that are not medically necessary.

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

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

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

• Telehealth Behavioral Health consult

$35 per consult

• CVS Health Virtual Care™ telehealth consult

$35 per consult

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

• The services are ordered by a physician or independently licensed behavioral health professional (BHP) and are directly related to an active treatment plan of care established by the physician or licensed BHP; and
• Care is appropriate for the active treatment of a condition, illness or disease; and
• Care is intermittent or hourly in nature*; and
• Care is provided under the supervision of an independently licensed BHP; and services take the place of a stay in a hospital or residential treatment facility (RTF), or receiving outpatient services outside of the home; and
• Treatment provided is appropriate for the member's condition including the amount of time spent providing the service as well as the frequency, type and duration of the services; and
• Services provided are not primarily for the comfort or convenience of the member or family or custodial in nature **.

* Intermittent or part-time skilled home behavioral health care is defined as a visit of up to 1 hour in duration.

** Custodial care is defined as services and supplies furnished to a person mainly to help him or her with activities of daily living. Custodial care includes services and supplies:

-Furnished mainly to train or assist the insured family member in personal hygiene and other activities of daily living rather than to provide therapeutic treatment; or

-That can be safely and adequately provided by persons without the technical skills of a health care provider (e.g., nurse).

$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 Section 3, “Other Services” under “You need prior Plan approval for certain services.” 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.

• 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

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

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

• Partial hospitalization treatment provided in a facility or program for mental health treatment provided under the direction of a physician
• Intensive outpatient program provided in a facility or program for mental health treatment provided under the direction of a physician
• Outpatient detoxification
• Ambulatory detoxification which is outpatient services that monitor withdrawal from alcohol or other substance abuse, including administration of medications
• Electro-convulsive therapy (ECT)
• Transcranial magnetic stimulation (TMS)
• Psychological/Neuropsychological testing

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

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)
• Medications prescribed to treat obesity

Note: Does not include GLP-1 medications for weight loss. See below for GLP-1 weight loss medications.

To obtain weight loss medications, you must enroll in the Weight Management Program. See program details within this section for additional information.

• Oral and Injectable Infertility medications (includes Artificial Insemination (AI), In vitro fertilization (IVF)/ART medications) (Limited to $25,000 per member per calendar year) 

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

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

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See Section 5(a)). 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.

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

$10 per Preferred Generic (PG) formulary drug;

$35 per Preferred Brand (PB) name formulary drug; and

$100 per covered Non-Preferred (NP) (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 Preferred Generic (PG) formulary drug;

$70 per Preferred Brand (PB) name formulary drug; and

$200 per covered Non-Preferred (NP) (generic or brand name) drug.

Weight loss medications: GLP-1 medication only

Note: To obtain approval for a GLP-1 medication for weight loss, you must enroll in the Weight Management Program. See program details within this section for additional information.

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

50% per covered formulary drug

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

50% per covered formulary drug.

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

Visit www.aetnafeds.com/familyplanning.php for more information on contraception and the exception process.

Once we have been contacted with exception request information sufficient for us to make a determination, you will receive a response within 24 hours or the next business day. Contraceptive exception requests are not subject to Section 8, The Disputed Claims Process.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5(a).

See Coverage Below

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 intrauterine devices
• Generic patch contraception

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

• 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 Preferred Brand (PB) name formulary drug; and

$100 per covered Non-Preferred (NP) (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 Preferred Brand (PB) name formulary drug; and

$200 per covered Non-Preferred (NP) (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 Specialty Drugs above for more information or visit: 
www.aetnafeds.com/pharmacy.php.

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

Preferred Specialty (PSP): 50% up to $350 maximum

Non-preferred Specialty (NPSP): 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.

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

$10 per Preferred Generic (PG) formulary drug;

$35 per Preferred Brand (PB) name formulary drug; and

$100 per covered Non-Preferred (NP) (generic or brand name) drug.

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
• HIV PrEP
• Nicotine Replacement Medications (Limits apply)
• Bowel Prep Medications (Required with preventive Colonoscopy)

Opioid rescue agents are covered under this Plan with no cost sharing when obtained with a prescription from an in-network pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at: https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to    https://www.findtreatment.samhsa.gov/

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

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

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

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 when administered under the direction of a Plan doctor (please see Durable Medical Equipment section in Section 5(a) for more information on what the plan will cover).
• Medical supplies such as dressings and antiseptics
• Drugs and supplies for cosmetic purposes
• Nonprescription medications unless specifically indicated elsewhere
• Lost, stolen or damaged drugs
• Drugs to enhance athletic performance
• Prophylactic drugs including, but not limited to, anti-malarials for travel
• Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
• Compounded thyroid hormone therapy
• Drugs prescribed in connection with Sex-Trait Modification for treatment of gender dysphoria

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

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

Annual Deductible

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

No Deductible

$5 per visit

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, 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.

800-628-3323

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

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

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.

If you need to visit a participating primary care provider for a covered service, and you are 50 miles or more away from home you may visit a primary care provider from our plan’s approved network.

• Call 800-537-9384 for provider information and location
• Select a doctor from 3 primary care providers in that area
• The Plan will authorize you for one visit and any tests or X-rays ordered by that primary care provider
• You must coordinate all subsequent visits through your own participating primary care provider.

Weight Management Program. Your plan includes a weight management program. Once you have been admitted to and are participating in the program, weight loss drugs prescribed under the plan are eligible for prescription drug cost sharing as outlined below. If you have been admitted to the program but are not participating according to program rules, prescribed weight loss drugs are not eligible for prescription drug cost sharing under the plan. You will be required to pay the full cost of any prescribed weight loss drug. Refer to Section 5(f). Prescription Drug Benefits for additional information.

In most cases, providers and facilities file HIPAA compliant electronic claims for you.  In cases where a paper claim must be used, the 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, P.O. Box 52444, Phoenix, AZ 85072-2444.

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.

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

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

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

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as 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.

Keep a separate record of the medical expenses of each covered family member.  Save copies of all medical bills, including those you accumulate to satisfy your deductible.  In most instances, they will serve as evidence of your claim.  We will not provide duplicate or year-end statements.

Please reply promptly when we ask for additional information.  We may delay processing or deny benefits for your claim if you do not respond.  Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.

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.

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employees 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.

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 or notify you of the status of OPM’s review 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. 

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/NAIC.php. When we are the primary payor, we pay the benefits described in this brochure.

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

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

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

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

We do not cover services that:

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

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

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

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

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

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party's insurance policies, your own insurance policies, or a 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.

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

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

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.

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

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

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

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

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

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

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

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 examples which 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 Provider
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.

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

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

To learn more about Medicare Advantage Plans, contact Medicare at 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. 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.

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

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

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 Section 5(b).
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs.  See Section 5(b).
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.  See Section 5(b).

See Section 4.

See Section 4.

See Section 4.

See Section 4.

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

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

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

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

Infertility is a disease defined as when a person is unable to conceive or produce conception after one year of egg-sperm contact when the individual attempting conception is under 35 years of age, or after six months of egg-sperm contact when the individual attempting conception is 35 years of age or older.  Egg-sperm contact can be achieved by regular sexual intercourse or artificial insemination (intrauterine, intracervical, or intravaginal) as stated in our medical clinical policy bulletin (see Section 10. for definition of Medical Necessity for additional details on Aetna’s Clinical Policy).  This definition applies to all individuals regardless of sexual orientation or the presence/availability of a reproductive partner.  Infertility may also be established by the demonstration of a disease or condition of the reproductive tract such that egg-sperm contact would be ineffective.

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

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

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

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

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

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.

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

Any claims that are not pre-service claims.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

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.

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).

A surprise bill is an unexpected bill you receive for

• Emergency care provided by nonparticipating providers – when you have little or no say in the facility or provider from whom you receive care, or for
• Non-emergency services provided by certain nonparticipating providers at participating health care facilities, or for
• Nonparticipating air ambulance services

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.

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

31

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

54

$175 per visit

55

$150 per visit

59

$150 per visit

59

Regular cost-sharing

61

$10 per Preferred Generic (PG) formulary drug;

$35 per Preferred Brand (PB) name formulary drug; and

$100 per Non-Preferred (NP) drug (generic or brand name).

66-67

$20 per Preferred Generic (PG) formulary drug;

$70 per Preferred Brand (PB) name formulary drug; and

$200 per Non-Preferred (NP) drug (generic or brand name).

66-67

Preferred Specialty (PSP): 50% up to a $350 maximum per prescription
Non-preferred Specialty (NPSP): 50% up to $700 maximum per prescription

68

Various copays, coinsurance, reduced fees or deductibles

72

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

41

Contact the Plan at 800-537-9384

74-75

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