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

Aetna HealthFund® CDHP / Aetna Value Plan

www.aetnafeds.com Customer service 888-238-6240

2021



IMPORTANT:
  • Rates
  • Changes for 2021
  • Summary of Benefits
  • Accreditations
An Individual Practice Plan with a Consumer Driven Health Plan (CDHP) Option and a Value Plan Option

Serving: In all 50 states and the District of Columbia

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 9 for details.  This Plan is accredited. See page 14.

Underwritten and administered by: Aetna Life Insurance Company

Enrollment in this Plan is limited: You must live or work in our geographic service area to enroll. See pages 19-23 for requirements.

Enrollment codes for: CT, DE, MA, ME, NH, NJ, NY, RI, VT
EP1 CDHP - Self Only              EP4 Value Plan - Self Only
EP3 CDHP - Self Plus One       EP6 Value Plan - Self Plus One
EP2 CDHP - Self and Family   EP5 Value Plan - Self and Family

Enrollment codes for: AL, AR, DC, FL, GA, LA, MD, NC, TN, VA, WV
F51 CDHP - Self Only             F54 Value Plan - Self Only
F53 CDHP - Self Plus One      F56 Value Plan - Self Plus One
F52 CDHP - Self and Family  F55 Value Plan - Self and Family

Enrollment codes for: AZ, CO, KS, MI, MO, NV, NM, SD, UT, WA
G51 CDHP - Self Only             G54 Value Plan - Self Only
G53 CDHP - Self Plus One      G56 Value Plan - Self Plus One
G52 CDHP - Self and Family  G55 Value Plan - Self and Family

Enrollment codes for: ID, IL, IA, KY, MN, MS, MT, ND, NE, OR, PA, WY
H41 CDHP - Self Only              H44 Value Plan - Self Only
H43 CDHP - Self Plus One       H46 Value Plan - Self Plus One
H42 CDHP - Self and Family   H45 Value Plan - Self and Family

Enrollment codes for: AK, CA, HI, IN, OH, OK, SC, TX, WI
JS1 CDHP - Self Only               JS4 Value Plan - Self Only
JS3 CDHP - Self Plus One        JS6 Value Plan - Self Plus One
JS2 CDHP - Self and Family    JS5 Value Plan - Self and Family

FEHB LogoOPM Logo








Important Notice

Important Notice from Aetna About Our Prescription Drug Coverage and Medicare

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

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

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

Please be advised

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

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY: 800-325-0778).
You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:
• Visit www.medicare.gov for personalized help.
• Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.




Table of Contents

(Page numbers solely appear in the printed brochure)

Table of Content



Introduction

This brochure describes the benefits of our Consumer Driven Health Plan and Value Plan under Aetna contract (CS 2938) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at 888-238-6240 or through our website: www.aetnafeds.com. The address for the Aetna* administrative office is:

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

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits.  You do not have a right to benefits that were available before January 1, 2021, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefits are effective January 1, 2021, and changes are summarized on page 24. Rates are shown at the end of this brochure.

*Health benefits and health insurance plans are offered, underwritten or administered by Aetna Life Insurance Company




Plain Language

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

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



Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except for your health care providers, authorized health benefits plan or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOBs) that you receive from us.
  • Periodically review your claims history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
    • Call the provider and ask for an explanation. There may be an error.
    • If the provider does not resolve the matter, call us at 888-238-6240 and explain the situation.
    • If we do not resolve the issue:

      CALL THE HEALTH CARE FRAUD HOTLINE

      877-499-7295

      OR go to:

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

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

      You can also write to:

      United States Office of Personnel Management
      Office of the Inspector General Fraud Hotline
      1900 E Street NW Room 6400
      Washington, DC 20415-1100

  • Do not maintain as a family member on your policy:
    • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
    • Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26).

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

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



Discrimination is Against the Law

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

You can also file a civil rights complaint with the Office of Personnel Management by mail at: Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Attention:  Assistant Director, FEIO, 1900 E Street NW, Suite 3400-S, Washington, DC 20415-3610.




Preventing Medical Mistakes

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

1. Ask questions if you have doubts or concerns.

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

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

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

3. Get the results of any test or procedure.

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

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

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

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

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

Patient Safety Links

For more information on patient safety, please visit:

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

Preventable Healthcare Acquired Conditions (“Never Events”)

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

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




FEHB Facts

Coverage information




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

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

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

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

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

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

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

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

  • Types of coverage available for you and your family

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

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

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

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

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

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

  • Family member coverage

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

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

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

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

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

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

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

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

  • Children’s Equity Act

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

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

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

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

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

  • When benefits and premiums start

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

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

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



When you lose benefits




TermDefinition
  • When FEHB coverage ends

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

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

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

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

  • Upon divorce

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

  • Temporary Continuation of Coverage (TCC)

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

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

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

  • Converting to individual coverage

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

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

  • Health Insurance Marketplace

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




Section 1. How This Plan Works

This Plan is an individual practice plan offering you a choice of a Consumer Driven Health Plan (CDHP) or a Value Plan.  OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Aetna holds the following accreditations: National Committee for Quality Assurance and/or the local plans and vendors that support Aetna hold accreditation from the National Committee for Quality Assurance. To learn more about this plan’s accreditation(s), please visit the following website:

General features of our Consumer Driven Health Plan (CDHP)

Our CDHP is a comprehensive consumer driven health plan that combines a traditional health plan with separate medical and dental funds that help you pay for covered medical and dental expenses. Aetna’s CDHP puts you first, can save you time and money, and gives you flexibility, choice and control.

For 2021, CDHP offers 100% in-network preventive care coverage, including dental. You have:

  • A consumer-controlled annual Medical Fund of $1,000/Self Only, $2,000/Self Plus One, or $2,000/Self and Family and an annual Dental Fund of $300/Self Only $600/Self Plus One, or $600/Self and Family to help you pay for eligible expenses. You use your Medical Fund first for covered medical expenses, then you need to satisfy your annual deductible. Once your deductible has been satisfied, the Traditional Medical Plan benefits will apply.
  • Opportunity to rollover unused Medical and Dental Funds for use in future years.
  • Online tools to help you manage your money and your health.
  • Freedom to choose the providers you wish to see – with no referrals.
  • A cap that limits the total amount you pay annually for eligible expenses.

Preventive care services for your CDHP

Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.

Deductible for your CDHP

Once you have exhausted your medical fund, the annual deductible of $1,000 for Self Only, $2,000 for Self Plus One and $2,000 for Self and Family in-network and $1,500 for Self Only, $3,000 for Self Plus One and $3,000 for Self and Family out-of-network, must be met before Traditional Medical Plan benefits are paid for care other than preventive care services. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. In-network and Out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

Catastrophic protection for your CDHP

We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and coinsurance cannot exceed $5,000 for Self Only enrollment, $10,000 for Self Plus One enrollment or $10,000 for Self and Family enrollment for in-network services or $6,000 for Self Only enrollment, $12,000 for Self Plus One enrollment or $12,000 for Self and Family enrollment for out-of-network 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.  In-network and Out-of-network out-of-pocket maximums do not cross apply and will need to be met separately in order for eligible medical expenses to be paid at 100%.

General features of our Value Plan

Our Value Plan is a comprehensive medical plan. You can see participating or nonparticipating providers without a referral. You also can earn health incentive credits to reduce your out of pocket medical costs (deductible and medical coinsurance).

Preventive care services for your Value Plan

Preventive care services are generally paid as first dollar coverage and are not subject to copayments, deductibles, or annual limits when received from a network provider.

Annual deductible for your Value Plan

The annual deductible of $700 for Self Only, $1,400 for Self Plus One, or $1,400 for Self and Family in-network and $1,400 for Self Only, $2,800 for Self Plus One, or $2,800 for Self and Family out-of-network, must be met before Plan benefits are paid for care other than preventive care services, PCP or Specialist office visits and prescription drugs. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. In-network and Out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

Catastrophic protection for your Value Plan

We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles, coinsurance and copayments cannot exceed $6,000 for Self Only enrollment, $12,000 for Self Plus One enrollment, or $12,000 for Self and Family enrollment for in-network services or $7,000 for Self Only enrollment, $14,000 for Self Plus One enrollment, or $14,000 for Self and Family enrollment for out-of-network 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. In-network and Out-of-network out-of-pocket maximums do not cross apply and will need to be met separately in order for eligible medical expenses to be paid at 100%.

Health education resources and accounts management tools

We have online, interactive health and benefits information tools to help you make more informed health decisions. (See pages 40 and 91).

We have Network Providers

Our network providers offer services through our Plan. When you use our network providers, you will receive covered services at reduced costs. In-network benefits apply only when you use a network provider. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. Aetna is solely responsible for the selection of network providers in your area. You can access network providers online by visiting our website at www.aetnafeds.com, or contact us for a directory or the names of network providers by calling 888-238-6240.

Out-of-network benefits apply when you use a non-network provider.

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies). The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

Network Providers

We negotiate rates with doctors, dentists and other health care providers to help save you money. We refer to these providers as “Network providers." These negotiated rates are our Plan allowance for network providers. We calculate a member’s coinsurance using these negotiated rates. The member is not responsible for amounts billed by network providers that are greater than our Plan allowance.

Non-Network Providers

Because they do not participate in our networks, non-network providers are paid by Aetna based on an out-of-network Plan allowance. Members are responsible for their coinsurance portion of our Plan allowance, as well as any expenses over that limit that the non-network provider may have billed. See the Plan allowance definition in Section 10 for more details on how we pay out-of-network claims.

Your rights and responsibilities

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM’s FEHB website (www.opm.gov/healthcare-insurance) lists the specific types of information that we must make available to you. Some of the required information is listed below.

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

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

If you want more information about us, call 888-238-6240 or write to Aetna at P.O. Box 550, Blue Bell, PA 19422-0550. You may also visit our website at www.aetnafeds.com.

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

Your medical and claims records are confidential

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

Medical Necessity

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

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

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

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

All benefits will be covered in accordance with the guidelines determined by Aetna.

Ongoing Reviews

We conduct ongoing reviews of those services and supplies which are recommended or provided by health professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such determination, you may then contact us to seek a review of the determination.

Authorization

Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits under this Plan. See section 3, "You need prior plan approval for certain services."

Patient Management

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

Where such use is appropriate, our utilization review/patient management staff uses nationally recognized guidelines and resources, such as Milliman Care Guidelines® and InterQual® ISD criteria, to guide the precertification, concurrent review and retrospective review processes. To the extent certain utilization review/patient management functions are delegated to integrated delivery systems, independent practice associations or other provider groups (“Delegates”), such Delegates utilize criteria that they deem appropriate.




TermDefinition
  • Precertification

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

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

Note: Since this Plan pays out-of-network benefits and you may self-refer for covered services, it is your responsibility to contact Aetna to precertify those services which require precertification. You must obtain precertification for certain types of care rendered by non- network providers to avoid a reduction in benefits paid for that care.
  • Concurrent Review
The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review.
  • Discharge Planning
Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by you upon discharge from an inpatient stay.
  • Retrospective Record Review
The purpose of retrospective record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions for coverage and payment of health care services. Our effort to manage the services provided to you includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and utilization concerns.



Member Services

Representatives from Member Services are trained to answer your questions and to assist you in using the Aetna plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free number on the card when you need to:

  • Ask questions about benefits and coverage.
  • Notify us of changes in your name, address or phone number.
  • Obtain information about how to file a grievance or an appeal.

Privacy Notice

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

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

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

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

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

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

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

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

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

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

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

If you want more information about us, call 888-238-6240, or write to Aetna, Federal Plans, PO Box 550, Blue Bell, PA 19422-0550. You may also contact us by fax at 860-975-1669 or visit our website at www.aetnafeds.com.




Service Area

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

Alabama, Most of Alabama, Enrollment Code F5  – Autauga, Baldwin, Bibb, Blount, Bullock, Calhoun, Chambers, Cherokee, Chilton, Choctaw, Clarke, Clay, Cleburne, Coffee, Colbert, Coosa, Covington, Crenshaw, Cullman, Dale, Dallas, De Kalb, Elmore, Escambia, Etowah, Fayette, Franklin, Geneva, Greene, Hale, Henry, Houston, Jackson, Jefferson, Lamar, Lauderdale, Lawrence, Lee, Limestone, Lowndes, Macon, Madison, Marengo, Marion, Marshall, Mobile, Monroe, Montgomery, Morgan, Perry, Pickens, Pike, Randolph, Russell, St. Clair, Shelby, Sumter, Talladega, Tallapoosa, Tuscaloosa, Walker, Washington, Wilcox and Winston counties.

Alaska, Most of Alaska, enrollment code JS - Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Fairbanks North Star, Haines, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Lake and Peninsula, Matanuska Susitna, Nome, North Slope, Prince of Wales Hyder, Sitka, Skagway, Hoonah Angoon, Southeast Fairbanks, Valdez Cordova, Yakutat and Yukon Koyukuk boroughs.

Arizona, Enrollment Code G5 - All of Arizona.

Arkansas, Most of Arkansas, Enrollment Code F5 - Arkansas, Baxter, Benton, Boone, Bradley, Carroll, Clark, Clay, Cleburne, Columbia, Conway, Craighead, Crawford, Crittenden, Cross, Dallas, Drew, Faulkner, Franklin, Fulton, Garland, Grant, Greene, Hot Spring, Independence, Jackson, Jefferson, Johnson, Lawrence, Lee, Lincoln, Logan, Lonoke, Madison, Marion, Miller, Mississippi, Monroe, Montgomery, Newton, Ouachita, Perry, Phillips, Poinsett, Polk, Pope, Prairie, Pulaski, Randolph, Saline, Scott, Sebastian, Sharp, St. Francis, Stone, Union, Van Buren, Washington, White, Woodruff and Yell counties.

California, Most of California, enrollment code JS - Alameda, Amador, Butte, Calaveras, Colusa, Contra Costa, El Dorado, Fresno, Humboldt, Imperial, Kern, Kings, Lake, Los Angeles, Madera, Marin, Merced, Monterey, Napa, Nevada, Orange, Placer, Riverside, Sacramento, San Benito, San Bernardino, San Diego, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Shasta, Solano, Sonoma, Stanislaus, Sutter, Tehama, Tulare, Tuolumne, Ventura, Yolo and Yuba counties.

Colorado, Enrollment Code G5 – All of Colorado.

Connecticut, Enrollment Code EP – All of Connecticut.

Delaware, Enrollment Code EP – All of Delaware.

District of Columbia, Enrollment Code F5 – All of Washington, DC.

Florida, Most of Florida, Enrollment Code F5 - Alachua, Baker, Bay, Bradford, Brevard, Broward, Calhoun, Charlotte, Citrus, Clay, Collier, Columbia, DeSoto, Dixie, Duval, Escambia, Flagler, Franklin, Gadsden, Gilchrist, Glades, Gulf, Hamilton, Hardee, Hendry, Hernando, Highlands, Hillsborough, Holmes, Indian River, Jackson, Jefferson, Lake, Lee, Leon, Levy, Liberty, Madison, Manatee, Marion, Martin, Miami-Dade, Monroe, Nassau, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Putnam, St. Lucie, Santa Rosa, Sarasota, Seminole, St. Johns, Sumter, Suwannee, Taylor, Union, Volusia, Wakulla, Walton and Washington counties.

Georgia, Enrollment Code F5 - All of Georgia

Hawaii, enrollment code JS - All of Hawaii.

Idaho, Most of Idaho, Enrollment Code H4 - Ada, Adams, Bannock, Bear Lake, Benewah, Bingham, Blaine, Boise, Bonner, Bonneville, Boundary, Camas, Canyon, Caribou, Cassia, Clark, Custer, Elmore, Franklin, Fremont, Gem, Gooding, Jefferson, Jerome, Kootenai, Latah, Lincoln, Madison, Minidoka, Nez Perce, Oneida, Owyhee, Payette, Shoshone, Teton, Twin Falls, Valley, and Washington counties.

Illinois, Most of Illinois, Enrollment Code H4 - Adams, Alexander, Bond, Boone, Brown, Bureau, Calhoun, Carroll, Cass, Champaign, Christian, Clark, Clay, Clinton, Coles, Cook, Crawford, Cumberland, De Kalb, Dewitt, Douglas, DuPage, Edgar, Edwards, Effingham, Fayette, Ford, Franklin, Fulton, Gallatin, Greene, Grundy, Hamilton, Hancock, Hardin, Henderson, Henry, Iroquois, Jackson, Jasper, Jefferson, Jersey, Jo Daviess, Johnson, Kane, Kankakee, Kendall, Knox, La Salle, Lake, Lawrence, Lee, Livingston, Logan, Macon, Macoupin, Madison, Marion, Marshall, Mason, Massac, McDonough, McLean, McHenry, Menard, Mercer, Monroe, Montgomery, Morgan, Moultrie, Ogle, Peoria, Perry, Piatt, Pike, Pope, Pulaski, Putnam, Randolph, Richland, Rock Island, St. Clair, Saline, Sangamon, Schuyler, Scott, Shelby, Stark, Stephenson, Tazewell, Union, Vermilion, Wabash, Warren, Washington, Wayne, White, Whiteside, Will, Williamson, Winnebago and Woodford counties.

Indiana, enrollment code JS - All of Indiana.

Iowa, Enrollment Code H4 - All of Iowa.

Kansas, Most of Kansas, Enrollment Code G5 - Allen, Anderson, Atchison, Barber, Barton, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Cheyenne, Clark, Clay, Cloud, Coffey, Comanche, Cowley, Crawford, Decatur, Dickinson, Doniphan, Douglas, Edwards, Elk, Ellis, Ellsworth, Finney, Ford, Franklin, Geary, Gove, Graham, Grant, Gray, Greeley, Greenwood, Hamilton, Harper, Harvey, Haskell, Hodgeman, Jackson, Jefferson, Jewell, Johnson, Kearny, Kiowa, Kingman, Labette, Lane, Leavenworth, Lincoln, Linn, Logan, Lyon, Marion, Marshall, McPherson, Meade, Miami, Mitchell, Montgomery, Morris, Morton, Nemaha, Neosho, Ness, Norton, Osage, Osborne, Ottawa, Pawnee, Phillips, Pottawatomie, Pratt, Rawlins, Reno, Republic, Rice, Riley, Rooks, Rush, Russell, Saline, Scott, Sedgwick, Seward, Shawnee, Sheridan, Sherman, Smith, Stafford, Stanton, Stevens, Sumner, Thomas, Trego, Wallace, Wabaunsee, Washington, Wichita, Wilson, Woodson, and Wyandotte counties.

Kentucky, Most of Kentucky, Enrollment Code H4 - Adair, Allen, Anderson, Ballard, Barren, Bath, Bell, Boone, Bourbon, Boyd, Boyle, Bracken, Breathitt, Breckinridge, Bullitt, Butler, Caldwell, Calloway, Campbell, Carlisle, Carroll, Carter, Casey, Christian, Clark, Clinton, Crittenden, Cumberland, Daviess, Edmonson, Elliott, Estill, Fayette, Fleming, Floyd, Franklin, Fulton, Gallatin, Garrard, Grant, Graves, Grayson, Green, Greenup, Hancock, Hardin, Harlan, Harrison, Hart, Henderson, Henry, Hopkins, Jefferson, Jessamine, Johnson, Kenton, Knott, Larue, Lawrence, Letcher, Lewis, Lincoln, Livingston, Logan, Lyon, Madison, Magoffin, Marion, Marshall, Martin, Mason, McCracken, McCreary, McLean, Meade, Menifee, Mercer, Metcalfe, Monroe, Montgomery, Morgan, Muhlenberg, Nelson, Nicholas, Ohio, Oldham, Owen, Pendleton, Perry, Pike, Powell, Pulaski, Robertson, Rowan, Russell, Scott, Shelby, Simpson, Spencer, Taylor, Todd, Trigg, Trimble, Warren, Washington, Wayne, Webster, Whitley, Wolfe and Woodford counties.

Louisiana, Most of Louisiana, Enrollment Code F5 - Acadia, Allen, Ascension, Assumption, Avoyelles, Beauregard, Bienville, Bossier, Caddo, Calcasieu, Caldwell, Cameron, Catahoula, Claiborne, De Soto, East Baton Rouge, East Carroll, East Feliciana, Evangeline, Franklin, Grant, Iberia, Iberville, Jackson, Jefferson, Jefferson Davis, La Salle, Lafayette, Lafourche, Lincoln, Livingston, Madison, Morehouse, Natchitoches, Orleans, Ouachita, Plaquemines, Pointe Coupee, Rapides, Red River, Richland, Sabine, Saint Bernard, Saint Charles, Saint Helena, Saint James, Saint Landry, Saint Martin, Saint Mary, Saint Tammany, St John The Baptist, Tangipahoa, Tensas, Terrebonne, Union, Vermilion, Vernon, Washington, Webster, West Baton Rouge, West Carroll, West Feliciana and Winn parishes and portions of the following counties as defined by the zip codes below:

Concordia - 71326, 71334, 71377

Maine, Enrollment Code EP – All of Maine.

Maryland, Enrollment Code F5 – All of Maryland.

Massachusetts , Most of Massachusetts, Enrollment Code EP – Barnstable, Berkshire, Bristol, Dukes, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk and Worcester counties.

Michigan, Enrollment Code G5 - All of Michigan.

Minnesota, Most of Minnesota, Enrollment Code H4 - Aitkin, Anoka, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Clearwater, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Hubbard, Isanti, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching, Lac Qui Parle, Lake, Lake Of The Woods, LeSueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk, Pope, Ramsey, Red Lake, Redwood, Renville, Rice, Rock, Roseau, St. Louis, Scott, Sherburne, Sibley, Stearns, Steele, Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca, Washington, Watonwan, Wilkin, Winona, Wright, and Yellow Medicine counties.

Mississippi, Most of Mississippi, Enrollment Code H4 - Adams, Alcorn, Amite, Attala, Benton, Bolivar, Calhoun, Carroll, Chickasaw, Claiborne, Clarke, Clay, Coahoma, Copiah, Covington, De Soto, Forrest, Franklin, George, Grenada, Hancock, Harrison, Hinds, Holmes, Issaquena, Itawamba, Jackson, Jefferson Davis, Jones, Lafayette, Lamar, Lauderdale, Lawrence, Leake, Lee, Leflore, Lincoln, Lowndes, Madison, Marion, Marshall, Monroe, Neshoba, Newton, Noxubee, Oktibbeha, Panola, Pearl River, Perry, Pike, Pontotoc, Prentiss, Quitman, Rankin, Scott, Simpson, Smith, Stone, Sunflower, Tallahatchie, Tate, Tippah, Tishomingo, Tunica, Union, Walthall, Warren ,Washington, Wayne, Webster, Yalobusha and Yazoo counties.

Missouri, Most of Missouri, Enrollment Code G5 - Adair, Andrew, Atchison, Audrain, Barry, Barton, Bates, Benton, Boone, Buchanan, Caldwell,  Callaway, Camden, Cape Girardeau, Carroll, Cass, Cedar, Chariton, Christian, Clark, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Daviess, De Kalb, Dent, Douglas, Franklin, Gasconade, Gentry, Greene, Grundy, Harrison, Hickory, Henry, Holt, Howard, Howell, Jackson, Jasper, Jefferson, Johnson, Knox, Laclede, Lafayette, Lawrence, Lewis, Lincoln, Linn, Livingston, Macon, Madison, Maries, McDonald, Mercer, Miller, Moniteau, Monroe, Montgomery, Morgan, Newton, Nodaway, Osage, Ozark, Pettis, Phelps, Platte, Polk, Pulaski, Putnam, Ralls, Randolph, Ray, Saint Clair, Saline, Schuyler, Scotland, Shannon, St. Charles, St. Francois, St. Louis, St. Louis City, Ste. Genevieve, Stone, Sullivan, Taney, Texas, Vernon, Warren, Washington, Webster, Worth and Wright counties.

Montana, South, Southeast and Western MT, Enrollment Code H4 -Beaverhead, Big Horn, Blaine, Broadwater, Carbon, Carter, Cascade, Chouteau, Custer, Daniels, Dawson, Deer Lodge, Fallon, Fergus, Flathead, Gallatin, Garfield, Glacier, Golden Valley, Granite, Hill, Jefferson, Judith Basin, Lake, Lewis And Clark, Liberty, Lincoln, Madison, Mccone, Meagher, Mineral, Missoula, Musselshell, Park, Petroleum, Phillips, Pondera, Powder River, Powell, Prairie, Ravalli, Richland, Roosevelt, Rosebud, Sanders, Sheridan, Silver Bow, Stillwater, Sweet Grass, Teton, Toole, Treasure, Valley, Wheatland, Wibaux and Yellowstone counties.

Nebraska, Enrollment Code H4 - All of Nebraska

Nevada , Las Vegas, Enrollment Code G5 – Carson City, Churchill, Clark, Douglas, Elko, Humboldt, Lander, Lyon, Mineral, Nye, Pershing, Storey, Washoe and White Pine counties.

New Hampshire, Enrollment Code EP – All of New Hampshire.

New Jersey, Enrollment Code EP – All of New Jersey.

New Mexico, Albuquerque, Dona Ana and Hobbs areas, Enrollment Code G5 - Bernalillo, Chaves, Cibola, Dona Ana, Lea, Los Alamos, Luna, Otero, San Juan, Sandoval, Santa Fe, Torrance, and Valencia counties.

New York, Most of New York, Enrollment Code EP -  Albany, Allegany, Bronx, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Dutchess, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Kings, Lewis, Livingston, Madison, Monroe, Montgomery, Nassau, New York, Niagara, Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, Steuben, Suffolk, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington, Wayne,  Westchester, Wyoming, and Yates counties and portions of the following counties as defined by the zip codes below:

Saint Lawrence - 12922, 12927, 12965, 12967, 13613, 13614, 13617, 13621, 13623, 13625, 13630, 13633, 13635, 13639, 13642, 13643, 13646, 13647, 13649, 13652, 13654, 13658, 13660, 13662, 13664, 13666, 13667, 13668, 13669, 13670, 13672, 13676, 13677, 13678, 13680, 13681, 13683, 13684, 13687, 13690, 13694, 13695, 13696, 13697, 13699

North Carolina, Enrollment Code F5 - All of North Carolina.

North Dakota, Most of North Dakota, Enrollment Code H4 - Barnes, Benson, Billings, Bottineau, Burleigh, Cass, Cavalier, Dickey, Eddy, Emmons, Foster, Grand Forks, Griggs, Kidder, Lamoure, Logan, McHenry, McIntosh, McLean, Mercer, Morton, Nelson, Oliver, Pembina, Pierce, Ramsey, Ransom, Richland, Rolette, Sargent, Sheridan, Sioux, Slope, Stark, Steele, Stutsman, Towner, Traill, Walsh, Ward and Wells counties.

Ohio, enrollment code JS  - All of Ohio.

Oklahoma, enrollment code JS - All of Oklahoma.

Oregon, Most of Oregon, Enrollment Code H4 - Baker, Benton, Clackamas, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Douglas, Gilliam, Harney, Hood River, Jackson, Jefferson, Josephine, Lane, Lincoln, Linn, Malheur, Marion, Multnomah, Polk, Tillamook, Umatilla, Union, Wasco, Washington and Yamhill counties.

Pennsylvania, Enrollment Code H4 - All of Pennsylvania.

Rhode Island, Enrollment Code EP - All of Rhode Island.

South Carolina, enrollment code JS - All of South Carolina.

South Dakota, Rapid City and Sioux Falls, Enrollment Code G5 - Bonne Homme, Butte, Clay, Custer, Fall River, Lawrence, Lincoln, Meade, Minnehaha, Pennington, Turner, Union, and Yankton counties.

Tennessee, Most of Tennessee, Enrollment Code F5 - City of Jackson and Anderson, Bedford, Benton, Bledsoe, Blount, Bradley, Campbell, Cannon, Carroll, Carter, Cheatham, Chester, Claiborne, Clay, Cocke, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Dyer, Fayette, Fentress, Franklin, Gibson, Giles, Grainger, Greene, Grundy, Hamblen, Hamilton, Hancock, Hardeman, Hardin, Hawkins, Haywood, Henderson, Henry, Hickman, Houston, Humphreys, Jefferson, Johnson, Knox, Lake, Lauderdale, Lawrence, Lewis, Lincoln, Loudon, Macon, Madison, Marion, Marshall, Maury, McMinn, McNairy, Meigs, Monroe, Montgomery, Moore, Morgan, Obion, Overton, Perry, Pickett, Polk, Putnam, Rhea, Roane, Robertson, Rutherford, Scott , Sequatchie, Sevier, Shelby, Smith, Stewart, Sullivan, Sumner, Tipton, Trousdale, Unicoi, Union, Van Buren, Warren, Washington, Wayne, Weakley, White, Williamson and Wilson counties.

Texas, enrollment code JS - All of Texas.

Utah - Most of Utah, Enrollment Code G5 - Beaver, Box Elder, Cache, Carbon, Davis, Duchesne, Emery, Garfield, Iron, Juab, Kane, Millard, Morgan, Piute, Rich, Salt Lake, San Juan, Sanpete, Sevier, Summit, Tooele, Uintah, Utah, Wasatch, Washington, Wayne and Weber counties.

Vermont, Enrollment Code EP - All of Vermont.

Virginia, Most of Virginia, Enrollment Code F5 – Albemarle, Alleghany, Amelia, Amherst, Appomattox, Arlington, Bedford, Bland, Botetourt, Bristol, Buchanan, Buckingham, Campbell, Caroline, Carroll, Charles City, Charlotte, Chesterfield, Clarke, Covington City, Craig, Culpeper, Cumberland, Dickenson, Dinwiddie, Essex, Fairfax, Fauquier, Floyd, Fluvanna, Franklin, Frederick, Galax City, Giles, Gloucester, Goochland, Grayson, Halifax, Hanover, Henrico, Henry, Isle Of Wight, James City, King And Queen, King George, King William, Lancaster, Lee, Loudon, Louisa, Lunenburg, Martinsville City, Mathews, Middlesex, Montgomery, Nelson, New Kent, Northumberland, Norton City, Nottoway, Orange, Patrick, Pittsylvania, Powhatan, Prince Edward, Prince George, Prince William, Pulaski, Radford, Roanoke, Roanoke City, Russell, Salem, Scott, Shenandoah, Smyth, Southampton, Spotsylvania, Stafford, Surry, Sussex, Tazewell, Warren, Washington, Westmoreland, Wise, Wythe and York counties and;

The cities of Alexandria, Charlottesville, Chesapeake, Colonial Heights, Covington, Danville, Fairfax, Falls Church, Franklin, Fredericksburg, Galax, Hampton, Harrisonburg, Hopewell, Lexington, Lynchburg, Manassas, Manassas Park, Martinsville, Newport News, Norfolk, Norton, Petersburg, Poquoson, Portsmouth, Richmond, Roanoke, Suffolk, Virginia Beach, Williamsburg and Winchester.

Washington, Most of Washington, Enrollment Code G5 – Adams, Asotin, Benton, Chelan, Clallam, Clark, Columbia, Cowlitz, Douglas, Ferry, Franklin, Garfield, Grant, Grays Harbor, Island, Jefferson, King, Kitsap, Kittitas, Klickitat, Lewis, Lincoln, Mason, Okanogan, Pacific, Pend Oreille, Pierce, San Juan, Skagit, Skamania, Snohomish, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, Whitman and Yakima counties.

West Virginia, Most of West Virginia, Enrollment Code F5 – Barbour, Berkeley, Boone, Braxton, Brooke, Cabell, Calhoun, Clay, Doddridge, Fayette, Gilmer, Grant, Greenbrier, Hampshire, Hancock, Hardy, Harrison, Jackson, Jefferson, Kanawha, Lewis, Lincoln, Logan, Marion, Marshall, Mason, McDowell, Mercer, Mineral, Mingo, Monongalia, Monroe, Morgan, Nicholas, Ohio, Pendleton, Pleasants, Pocahontas, Preston, Putnam, Raleigh, Randolph, Ritchie, Roane, Summers, Taylor, Tyler, Tucker, Upshur, Wayne, Webster, Wetzel, Wirt, Wood and Wyoming counties.

Wisconsin, enrollment code JS - All of Wisconsin.

Wyoming, Enrollment Code H4 - All of Wyoming.

If you or a covered family member move or live outside of our service areas, you can continue to access out-of-network care or you can enroll in another plan.  If you or a covered family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.




Section 2. Changes for 2021

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Changes to our Consumer Driven Health Plan (CDHP) and Value Plan

  • Enrollment code EP. Your share of the non-Postal premium under the Consumer Driven Health Plan (CDHP) option will increase for Self Only, Self Plus One, and Self and Family. Your share of the non-Postal premium under the Value Plan option will increase for Self Only, Self Plus One, and Self and Family. (See page 169)
  • Enrollment code F5. Your share of the non-Postal premium under the Consumer Driven Health Plan (CDHP) option will increase for Self Only, Self Plus One, and Self and Family. Your share of the non-Postal premium under the Value Plan option will decrease for Self Only, Self Plus One, and Self and Family. (See page 168)
  • Enrollment code G5. Your share of the non-Postal premium under the Consumer Driven Health Plan (CDHP) option will increase for Self Only, Self Plus One, and Self and Family. Your share of the non-Postal premium under the Value Plan option will decrease for Self Only, Self Plus One, and Self and Family. (See page 169)
  • Enrollment code H4. Your share of the non-Postal premium under the Consumer Driven Health Plan (CDHP) option will decrease for Self Only, Self Plus One, and Self and Family. Your share of the non-Postal premium under the Value Plan option will decrease for Self Only, Self Plus One, and Self and Family. (See page 169)
  • Enrollment code JS. Your share of the non-Postal premium under the Consumer Driven Health Plan (CDHP) option will decrease for Self Only, Self Plus One, and Self and Family. Your share of the non-Postal premium under the Value Plan option will increase for Self Only, Self Plus One, and Self and Family. (See page 170)
  • Services that require plan approval (other services) – The Plan updated its list of services that require plan approval. Services that now must be preauthorized are: Functional endoscopic sinus surgery, Arthrodesis for spine deformity and Kyphectomy. (See page 26)
  • Specialty drugs - The Plan will now require members to fill all specialty drugs at an Aetna Performance Specialty Network pharmacy. (See pages 84 and 130)
  • True accumulation for specialty drugs - The Plan will now apply true accumulation. Some specialty medications may qualify for third-party copayment assistance programs that could lower your out-of-pocket costs for those products. For any such specialty medication where third-party copayment assistance is used, the member shall not receive credit toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. (See pages 85 and 131)
  • Voluntary maintenance choice - Through voluntary maintenance choice, members can fill maintenance drugs (30-90 day supply) either through home delivery or at CVS pharmacy retail locations. (See pages 86 and 132)

Changes to our Consumer Driven Health Plan (CDHP)

  • See above for changes that apply to both CDHP and Value plans.

Changes to our Value Plan

  • Treatment therapies - The Plan is changing the in-network benefit from 20% of the Plan allowance (no deductible) to $40 per specialist visit (no deductible). (See page 103)

  • Intravenous (IV) infusion therapy and medication – The Plan is changing the in-network benefit from a coinsurance of 20% of the Plan allowance (no deductible) to a copayment of $40 per specialist visit (no deductible). (See page 107)

  • Habilitative Services - The Plan is changing the in-network benefit from $25 per PCP visit, $40 per specialist visit (no deductible) to 20% of the Plan allowance (no deductible). (See page 104)




Section 3. How You Get Care

TermDefinition

Identification cards

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

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

Where you get covered care

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

Network providers

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

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

Network facilities

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

Non-network providers and facilities You can access care from any licensed provider or facility. Providers and facilities not in Aetna’s networks are considered non-network providers and facilities.
What you must do to get covered care

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

Transitional care

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

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

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

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

Hospital care

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

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

If you are hospitalized when your enrollment begins

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

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

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

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

You need prior Plan approval for certain services

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

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

  • Inpatient hospital admission

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

  • Other services

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

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

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

Inpatient confinements (except hospice) - For example, surgical and nonsurgical stays; stays in a skilled nursing facility or rehabilitation facility; and maternity and newborn stays that exceed the standard length of stay (LOS)

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

*For complete list refer to:

https://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.

You or your physician must obtain an approval for certain durable medical equipment (DME) including but not limited to electric or motorized wheelchairs and electric scooters.

Members must call Member Services at 888-238-6240 for authorization.

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

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

Next, provide the following information:

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

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

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

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

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

  • Non-urgent care claims

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

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

  • Urgent care claims

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

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

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

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

  • Concurrent care claims

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

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

  • Emergency inpatient admission

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

  • Maternity care

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

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

  • If your treatment needs to be extended

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

What happens when you do not follow the precertification rules when using non-network facilities

  • If no one contacts us, we will decide whether the hospital stay was medically necessary.
    • If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.
    • If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.
  • If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.
  • When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:
    • for the part of the admission that was medically necessary, we will pay inpatient benefits, but
    • for the part of the admission that was not precertified or not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.
Circumstances beyond our controlUnder certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.  In that case, we will make all reasonable efforts to provide you with the necessary care.
If you disagree with our pre-service claim decision

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

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

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

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

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

2.  Ask you or your provider for more information.

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

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

3.  Write to you and maintain our denial.

  • To reconsider an urgent care claim

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

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

  • To file an appeal with OPM

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

The Federal Flexible Spending Account Program – FSAFEDS

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



Section 4. Your Cost for Covered Services

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



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

Copayments

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

Deductible

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

Consumer Driven Health Plan (CDHP)

After you have used up your Medical Fund, you must satisfy your deductible. Your deductible is $1,000 for Self Only, $2,000 for Self Plus One or $2,000 for Self and Family enrollment in-network and $1,500 for Self Only, $3,000 for Self Plus One and $3,000 for Self and Family out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

Note: If you change plans (*except if you change Aetna CDHP options) 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.

*Note: If you change from one Aetna CDHP option to another Aetna CDHP option during Open Season then you will receive your annual Medical Fund and your annual deductible will begin on January 1, regardless of your open season effective date.

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

Value Plan

You must satisfy your deductible before your Traditional medical coverage begins. Note: Preventive services, PCP office visits and Specialist office visits are not subject to the annual deductible.  Your annual deductible is $700 for a Self Only enrollment, $1,400 for a Self Plus One enrollment and $1,400 for Self and Family enrollment in-network and $1,400 for a Self Only enrollment, $2,800 for a Self Plus One, and $2,800 for a Self and Family enrollment out-of-network.  Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

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

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

Coinsurance

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

Example: You pay 15% of our Plan allowance for in-network durable medical equipment under CDHP and 20% of our Plan allowance under the Value Plan.

Differences between our Plan allowance and the bill

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

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

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

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

What your plan pays (plan coinsurance):  85% in-network/60% out-of-network

What you pay (coinsurance): 15% in-network/40% out-of-network

Your CDHP out-of-pocket maximum: $5,000/$10,000 in-network; $6,000/$12,000 out-of-network***

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

 

In-network

Hospital bill: Amount billed: $25,000
Amount Aetna uses to calculate payment: in-network rate* $8,750
Amount Aetna uses to calculate payment: Recognized amount** out-of-network
What your Aetna plan will pay: Negotiated /recognized amount: $8,750
What your Aetna plan will pay: Percent your plan pays: 85%
What your Aetna plan will pay: Aetna’s negotiated rate/recognized amount covered under plan: $7,437.50
What you owe: Your coinsurance responsibility (In-network 15%, Out-of-network 40%): $1,312.50
What you owe: Amount that can be balance billed to you: $0
What you owe: Your Total Responsibility: $1313.50

Out-of-network

Hospital bill: Amount billed: $25,000
Amount Aetna uses to calculate payment: in-network rate* 
Amount Aetna uses to calculate payment: Recognized amount** out-of-network: $8,750
What your Aetna plan will pay: Negotiated /recognized amount: $8,750
What your Aetna plan will pay: Percent your plan pays: 60%
What your Aetna plan will pay: Aetna’s negotiated rate/recognized amount covered under plan: $5,250
What you owe: Your coinsurance responsibility (In-network 15%, Out-of-network 40%): $3,500
What you owe: Amount that can be balance billed to you: $16,250
What you owe: Your Total Responsibility: $19,750

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

**When you go out of network, Aetna determines a recognized amount. You may be responsible for the difference between the billed amount and the recognized amount. In these examples, we have assumed that the recognized amount and the negotiated rate are the same amount. Actual amounts will vary.

***Your plan caps out-of-pocket costs for covered services. The deductible and coinsurance you owe count toward that cap. But when you go out of network, the difference between the health care provider’s bill and the recognized amount does not count toward that cap.

Your catastrophic protection out-of-pocket maximum

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

CDHP

Only your deductible and those out-of-pocket expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the out-of-pocket maximums. This includes dollars you have paid toward your deductible and coinsurance.

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

If you have met your deductible the following would apply:

Self Only:

In-network: Your annual out-of-pocket maximum is $5,000.

Out-of-network: Your annual out-of-pocket maximum is $6,000.

Self Plus One:

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

Out-of-network: Your annual out-of-pocket maximum is $12,000.

Self and Family:

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

Out-of-network: Your annual out-of-pocket maximum is $12,000.

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

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

Value Plan

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

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

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

Self Only:

In-network:  Your annual out-of-pocket maximum is $6,000.

Out-of-network:  Your annual out-of-pocket maximum is $7,000.

Self Plus One:

In-network: Your annual out-of-pocket maximum is $12,000.

Out-of-network: Your annual out-of-pocket maximum is $14,000.

Self and Family:

In-network:  Your annual out-of-pocket maximum is $12,000.

Out-of-network: Your annual out-of-pocket maximum is $14,000.

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

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

Carryover

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

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

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



Section 5. Consumer Driven Health Plan Benefits (CDHP)

See page 24 for how our benefits changed this year and pages 164-165 for a benefits summary.




(Page numbers solely appear in the printed brochure)

Table of Content



Section 5. Consumer Driven Health Plan Benefits Overview (CDHP)

This Plan offers a Consumer Driven Health Plan (CDHP). The CDHP benefit package is described here in this Section. Make sure that you review the benefits that are available under the benefit product in which you are enrolled.

CDHP Section 5, which describes the CDHP benefits, is divided into subsections. Please read Important things you should keep in mind at the beginning of each subsection. Also, read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about CDHP benefits, contact us at 888-238-6240 or on our website at www.aetnafeds.com.

The Aetna HealthFund Consumer Driven Health Plan (CDHP) focuses on you, the health care consumer, and gives you greater control in how you use your health care benefits. With this Plan, eligible in-network medical and dental preventive care is covered in full, and you can use the Medical Fund for any other covered care. If you use up your Medical Fund, the Traditional medical coverage begins after you satisfy your deductible.  If you don’t use up your Medical Fund for the year, you can roll it over to the next year, up to the maximum rollover amount ($5,000 Self Only enrollment/ $10,000 Self Plus One enrollment/ $10,000 Self and Family enrollment), as long as you continue to be enrolled in the Aetna HealthFund CDHP.

The Aetna HealthFund CDHP includes these five key components: 




TermDefinition
  • In-Network Medical and Dental Preventive Care

This component covers 100% for preventive care for adults and children if you use a network provider. The covered medical services include office visits/exams, immunizations and screenings, and the covered dental services include oral evaluations, cleanings, X-rays, fluoride applications, sealants, and space maintainers. These services are fully described in Section 5. The services are based on recommendations by the American Medical Association, the American Academy of Pediatrics, and the American Dental Association. You do not have to meet the deductible before using these services.

  • Aetna HealthFund (Medical and Dental Funds)

The Plan provides an annual Medical Fund for each enrollment. For 2021, the Plan provides $1,000 for a Self Only enrollment, $2,000 for a Self Plus One enrollment, or $2,000 for a Self and Family enrollment. The Medical Fund covers 100% of your eligible medical expenses. The Medical Fund is described in greater detail in Section 5.

Health Incentive Credit:  The Plan will provide a health incentive credit for an enrollee or spouse who completes the Plan's health Assessment," and an online digital coaching. The Plan will credit the Medical Fund $50 per enrollee and/or spouse up to an annual family limit of $100 upon completion of the health assessment and online digital coaching. 

Biometric Screening with Incentive: (Available February 1st - December 31st) The Plan will provide biometric screenings for enrollee and/or spouse (over 18 years of age) with no cost sharing.  Biometric screenings must include total cholesterol, HDL, calculated LDL, calculated cholesterol/HDL ratio, triglycerides and glucose, blood pressure and waist circumference. The Plan will credit the member’s medical fund with an incentive of $50 per enrollee and/or spouse, up to an annual family limit of $100 for biometric screening.  Members obtain the screening at a Quest Diagnostics Patient Service Center (PSC).  If you are not located within 20 miles of a Quest Diagnostics PSC, you may send the appropriate form to your physician's office and request that your physician complete the form and fax or mail it back to Quest.  Visit www.aetnafeds.com for information on setting up an appointment at a Quest PSC or to obtain the form if you are not located within 20 miles of a Quest PSC.  

The Plan also provides an annual Dental Fund for each enrollment. Each year, the Plan provides $300 for a Self Only enrollment, $600 for a Self Plus One enrollment or $600 for a Self and Family enrollment.

The Dental Fund covers 100% of your eligible dental expenses. The Dental Fund is described in greater detail in Section 5.

Note: You cannot use available dental funds for covered services that you have exhausted the annual limits. (example: 2 cleanings per year)

If you have an unused Medical or Dental Fund balance at the end of the calendar year, that balance will roll over so you can use it in the future, as long as you continue to participate in the Plan. If you terminate your participation in the Plan, your Medical and Dental Fund balances are lost.

The Medical Fund is not a cash account and has no cash value.  It does not duplicate other coverage provided by this brochure.  It will be terminated if you are no longer covered by this Plan.  Only eligible expenses incurred while covered under the Plan will be eligible for reimbursement subject to timely filing requirements.  Unused Medical Funds are forfeited if you are no longer covered under the Plan.

Note: In-Network Medical and Dental Preventive Care benefits paid under Section 5 do NOT count against your Medical or Dental Funds.

  • Traditional medical coverage subject to the deductible

Under Traditional medical coverage, you must first use your annual Medical Fund and then satisfy your deductible of $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment or $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. Once you have satisfied your deductible, the Plan generally pays 85% of the cost for in-network care and 60% for out-of-network care.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

  • Catastrophic protection for out-of-pocket expenses

When you use network providers, your annual maximum for out-of-pocket expenses (deductible and coinsurance) for covered services is limited to $5,000 for Self Only, $10,000 for Self Plus One, or $10,000 for Self and Family enrollment. If you use non-network providers, your out-of-pocket maximum is $6,000 for Self Only, $12,000 for Self Plus One, or $12,000 for Self and Family enrollment. 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, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-pocket maximum and CDHP Section 5 Traditional medical coverage subject to the deductible for more details.  In-network and Out-of-network out-of-pocket maximums do not cross apply and will need to be met separately in order for eligible medical expenses to be paid at 100%.

  • Health education resources and account management tools

Connect to www.aetnafeds.com for access to Aetna Member website, a secure and personalized member site offering you a single source for health and benefits information. Use it to:

  • Perform self-service functions, like checking your fund balance or the status of a claim.

Aetna Member website gives you direct access to:

  • Care and Costs tools that compare in-network and out-of-network provider fees, the cost of brand-name drugs vs. their generic equivalents, and the costs for services such as routine physicals, emergency room visits, lab tests, X-rays, MRIs, etc.
  • Real-time, out-of-pocket estimates for medical expenses based on your Aetna health plan.  You can compare the cost of doctors and facilities before you make an appointment, helping you budget for an manage health care expenses. 
  • A hospital comparison tool that allows you to see how hospitals in your area rank on measures important to your care.
  • Our online provider directory.
  • Online customer service that allows you to request member ID cards, send secure messages to Member Services, and more.
  • Tools and resources to help you manage your health with access to your health assessment, digital coaching, personal health record, and more.



Section 5. Medical and Dental Preventive Care (CDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Preventive care is health care services designed for prevention and early detection of illness in average risk, people without symptoms, generally including routine physical examinations, tests and immunizations.  We follow the U.S. Preventive Services Task Force recommendations for preventive care unless noted otherwise.  For more information visit www.aetnafeds.com.
  • The Plan pays 100% for the medical and dental preventive care services listed in this Section as long as you use a network provider.
  • If you choose to access preventive care with an out-of-network provider, you will not qualify for 100% preventive care coverage. Please see Section 5 – Medical and Dental Funds, and Section 5 – Traditional medical coverage subject to the deductible.
  • For preventive care not listed in this Section or preventive care from a non-network provider, please see Section 5 – Medical and Dental Funds.
  • For all other covered expenses, please see Section 5 – Medical and Dental Funds and Section 5 – Traditional medical coverage subject to the deductible.
  • Note that the in-network medical and dental preventive care paid under this Section does NOT count against or use up your Medical or Dental Funds.



Benefit Description : Medical Preventive Care, adult CDHP (You pay)
  • Routine physicals - one (1) exam every calendar year

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

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

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above your Medical Fund are subject to your deductible until satisfied and then subject to Traditional medical coverage (see Section 5).

Routine mammogram - covered for women

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

 

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above your Medical Fund are subject to your deductible until satisfied and then subject to Traditional medical coverage (see Section 5).
  • Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.
     
    • The following exams limited to:
      • One (1) routine eye exam every 12 months
      • One (1) routine hearing exam every 24 months

Note: Some tests provided during a routine physical may not be considered preventive. Contact Member Services at 888-238-6240 for information on whether a specific test is considered routine.

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

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above your Medical Fund are subject to your deductible until satisfied and then subject to Traditional medical coverage (see Section 5).

Not covered:

  • Physical exams, immunizations and boosters required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams or travel.  
  • Immunizations, boosters, and medications for travel or work-related exposure.
All charges
Benefit Description : Medical Preventive Care, childrenCDHP (You pay)
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org
  • Well-child care charges for routine examinations, immunizations and care (up to age 22)
    • Seven (7) routine exams from birth to age 12 months
    • Three (3) routine exams from age 12 months to 24 months
    • Three (3) routine exams from age 24 months to 36 months
    • One (1) routine exam per year thereafter to age 22
  • Hearing loss screening of newborns provided by a participating hospital before discharge
  • One (1) routine eye exam every 12 months through age 17 to determine the need for vision correction
  • One (1) routine hearing exam every 24 months through age 17 to determine the need for hearing correction

Note: Some tests provided during a routine physical may not be considered preventive. Contact Member Services at 888-238-6240 for information on whether a specific test is considered routine.

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

In-network: Nothing at a network provider.

Out-of-network: Nothing at a non-network provider up to your available Medical Fund balance. Charges above your Medical Fund are subject to your deductible until satisfied and then subject to Traditional medical coverage (see Section 5).

Not covered:

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

Preventive care limited to:

  • Prophylaxis (cleaning of teeth – limited to two (2) treatments per calendar year)
  • Fluoride applications (limited to one (1) treatment per calendar year for children under age 16)
  • Sealants – (once every three (3) years, from the last date of service, on permanent molars for children under age 16)
  • Space maintainer (primary teeth only)
  • Bitewing X-rays (one (1) set per calendar year)
  • Complete series X-rays (one (1) complete series every three (3) years)
  • Periapical X-rays
  • Routine oral evaluations (limited to two (2) per calendar year)

Participating network PPO dentists offer members services at a negotiated rate – so, you are generally charged less for your dental care when you visit a participating network PPO dentist. Refer to our online provider directory at www.aetnafeds.com to find a participating network PPO dentist, or call Member Services at 888-238-6240.

In-network: Nothing at a network dentist

Out-of-network: Nothing at a non-network dentist up to your available Dental Fund balance. However, you are responsible for non-network dentist fees that exceed our Plan allowance. See Section 5 Dental Fund.



Section 5. Medical and Dental Funds (CDHP)

Important things you should keep in mind about your Medical Fund benefits:

  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • All eligible medical care expenses up to the Plan allowance in Section 5 (except in-network medical preventive care) are paid from your Medical Fund. Traditional medical coverage will start once your deductible is satisfied.
  • Note that in-network medical preventive care covered under Section 5 does NOT count against your Medical Fund.
  • The Medical Fund provides full coverage for eligible expenses from both in-network and non-network providers. However, your Medical Fund will generally go much further when you use network providers because network providers agree to discount their fees.  Note: The Medical Fund does not reduce the deductible and/or the out-of-pocket maximum.
  • You can track your Medical Fund on the Aetna Member website, by phone at 888-238-6240 (toll-free), or, when you incur claims, with monthly statements mailed directly to you at home.
  • Whenever you join this Plan, your annual Deductible will apply as of your effective date. The Plan will prorate the amount of the annual Medical Fund for members who join the Plan outside of the annual Open Season. If you join at any other time during the year, your Medical Fund for your first year will be prorated at a rate of $83 per month for Self Only or $167 per month for Self Plus One or Self and Family for each full month of coverage remaining in that calendar year. If your enrollment effective date falls between the first and fifteenth day of the month, you will be given credit as of the first of the month. If your enrollment effective date is the sixteenth or later in the month, you will be given credit as of the first of the following month.
  • If a subscriber begins the year under Self Only enrollment and then switches to Self Plus One or Self and Family enrollment, the Medical Fund will increase from $1,000 to $2,000.We will deduct any amounts used while under the Self Only enrollment from the Self Plus One or Self and Family enrollment of $2,000.
  • If the subscriber begins the year under Self Plus One or Self and Family enrollment and later switches to Self Only enrollment, the Medical Fund will decrease from $2,000 to $1,000. We will deduct amounts of the Medical Fund previously used while enrolled in the Self Plus One or Self and Family from the Self Only enrollment amount of $1,000. For example, if $650 of the Self and Family Medical Fund had been used and the subscriber changes to Self Only coverage, the Medical Fund will be $1,000 minus $650 or $350 for the balance of the year. Members will not be penalized for amounts used while in Self Plus One or Self and Family enrollment that exceed the amount of the Self Only Medical Fund.
  • Medicare premium reimbursement – Medicare participating annuitants may request reimbursement for Medicare premiums paid if Medical Fund dollars are available. Please contact us at 888-238-6240 for more information.
  • If you terminate your participation in this Plan, any remaining Medical Fund balance will be forfeited.
  • YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.



Benefit Description : Medical fund CDHP (You pay)

A Medical Fund is provided by the Plan for each enrollment. Each year the Plan adds to your account. For 2021 the Medical Fund is:

  • $1,000 per year for a Self Only enrollment, or;
  • $2,000 per year for a Self Plus One or Self and Family enrollment.

The Medical Fund covers eligible expenses at 100%. For example, if you are ill and go to a network doctor for a $75 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your Medical Fund; you pay nothing.

Balance in Medical Fund for Self Only $1,000
Less: Cost of visit                                       - 75
Remaining Balance in Medical Fund     $   925

Medical Fund expenses are the same medical, surgical, hospital, emergency, mental health and substance misuse, and prescription drug services and supplies covered under the Traditional medical coverage (see Section 5 for details).

To make the most of your Medical Fund, you should:

  • Use the network providers whenever possible; and
  • Use generic prescriptions whenever possible

Medical Fund Rollover

Provided you remain enrolled in the CDHP, any unused, remaining balance in your Medical Fund at the end of the calendar year may be rolled over to subsequent years.

Note: This rollover feature can increase your Medical Fund in the following year(s) up to a maximum rollover of $5,000 Self Only enrollment or $10,000 Self Plus One or Self and Family enrollment.

Health Incentive Credit

The Plan will provide a health incentive credit for an enrollee or spouse who completes the Plan's health assessment, and online digital coaching. The Plan will credit the Medical Fund $50 per enrollee and/or spouse up to an annual family limit of $100 upon completion of the health assessment, and online digital coaching. 

In-network and out-of-network: Nothing up to your available Medical Fund balance.  However, you are responsible for non-network medical fees that exceed our Plan allowance.

Not covered:

  • Non-network preventive care services not included under Section 5
  • Services or supplies shown as not covered under Traditional medical coverage (see Section 5)
  • Charges of non-network providers that exceed our Plan allowance.
All charges



Dental Fund (CDHP)

Important things you should keep in mind about your Dental Fund benefits:

  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Note that in-network preventive dental care covered under Section 5 does NOT count against your Dental Fund.
  • You cannot use available dental funds for covered services that you have exhausted the annual limits. (example: 2 cleanings per year)
  • Provided you remain enrolled in the CDHP, any unused, remaining balance in your Dental Fund at the end of the calendar year, will be rolled over to subsequent years.
  • When you join this Plan, you will have access to the entire Dental Fund ($300 for Self Only, $600 for Self Plus One, or $600 for Self and Family) to share between you and your enrolled family members.
  • Participating network PPO dentists offer members services at a negotiated rate – so, you are generally charged less for your dental care when you visit a participating network PPO dentist. Refer to our  online provider directory at www.aetnafeds.com to find a participating network PPO dentist, or call Member Services at 888-238-6240.
  • All eligible dental expenses will be paid from your Dental Fund. You can track your Dental Fund on Aetna’s Member website or by phone at 888-238-6240. Note: Once your fund is exhausted, you may continue to save on the cost of your dental care with access to the discounted fees offered by participating network PPO dentists. Discounts may not be available in all states.
  • If you are enrolled in a FEDVIP Dental Plan, the FEDVIP plan will pay first for dental services and your Dental Fund will pay second, except for diagnostic and preventive care. When you use an in-network provider, diagnostic and preventive care will be reimbursed at 100% and does not count against your Dental Fund. When you use a non-network dentist for these services, the Dental Fund will pay first and your FEDVIP plan will pay second. See page 148.
  • You can visit any licensed dentist for covered services under the Dental Fund. However, you can make your Dental Fund go further by taking advantage of the negotiated rates offered by a participating network PPO dentist. These negotiated rates are generally less than the dentist’s usual fees.
  • REMEMBER: If you terminate your participation in this Plan, any Dental Fund balance you may have will be lost.



Benefit Description : Dental fundCDHP (You pay)

Dental Fund expenses include dental services up to a maximum of $300 for Self Only, $600 for Self Plus One or $600 for Self and Family enrollment.

The Dental Fund covers eligible expenses at 100%. For example, if you go to a network dentist and incur charges of $125 for fillings, the dentist will submit your claim and the cost of the visit will be deducted automatically from your Dental Fund; you pay nothing.

Balance in Dental Fund for Self Only $300
Less: Cost of fillings                            -125

Remaining Balance in Dental Fund     $175

 

Dental Fund Rollover

Provided you remain enrolled in the CDHP, any unused remaining balance in your Dental Fund at the end of the calendar year will be rolled over to subsequent years.

Eligible dental covered services include:

Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance.

Note: Once your Dental Fund is exhausted, you may pay the discounted fees offered by participating network PPO dentists. Discounts may not be available in all states. You are responsible for the full charges for services accessed from a non-network dentist.

Accidental injury benefit: 

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

Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance.

Note: Once your Dental Fund is exhausted, you may pay the discounted fees offered by participating network PPO dentists. Discounts may not be available in all states. You are responsible for the full charges for services accessed from a non-network dentist.      

Diagnostic and Preventive Care From Non-Network Dentists:

  • Prophylaxis (cleaning of teeth – limited to two (2) treatments per calendar year) 
  • Fluoride applications (limited to one (1) treatment per calendar year for children under age 16)
  • Sealants – (once every three (3) years, from the last date of service, on permanent molars for children under age 16)
  • Space maintainer (primary teeth only)
  • Bitewing X-rays (one (1) set per calendar year)
  • Complete series X-rays (one (1) complete series every three (3) years)
  • Periapical X-rays
  • Routine oral evaluations (limited to two (2) per calendar year)

Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance.

Note: Once your Dental Fund is exhausted, you may pay the discounted fees offered by participating network PPO dentists. Discounts may not be available in all states. You are responsible for the full charges for services accessed from a non-network dentist.

Restorative Care (Basic and Major) from Network or Non-Network Dentists:

  • Amalgam and resin-based composite restorations (“fillings”)
  • Inlays and onlays
  • Crowns
  • Fixed partial dentures (“bridgework”)
  • Root canal (“endodontics”) therapy, including necessary X-rays
  • Extractions (oral surgery) such as simple, surgical, soft tissue and bony impacted teeth
  • Osseous surgery (“periodontics”) - one (1) per quadrant every three (3) years, from the last date of service
  • General anesthesia and intravenous sedation
  • Repairs to removable partial dentures and complete dentures, within six (6) months of installation
  • Occlusal guards (for bruxism only) – limited to one every three (3) years, from the last date of service

Nothing for eligible expenses until you exhaust your Dental Fund. However, you are responsible for non-network dentist fees that exceed our Plan allowance.

Note: Once your Dental Fund is exhausted, you may pay the discounted fees offered by participating network PPO dentists. Discounts may not be available in all states. You are responsible for the full charges for services accessed from a non-network dentist.

Not covered:

  • Orthodontia
  • Dental treatment for cosmetic purposes
  • Dental care involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Dental implants
  • Replacement of crowns, fixed partial dentures (bridges), removable partial dentures or complete dentures, if the existing crown, fixed partial denture (bridge), removable partial denture or complete denture was originally placed less than eight (8) years prior to the replacement.
  • Charges of non-network providers that exceed our Plan allowance
All charges



Section 5. Traditional Medical Coverage Subject to the Deductible (CDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Your deductible is $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment, and $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.
  • Your Medical Fund ($1,000 Self Only enrollment, $2,000 for Self Plus One enrollment, and $2,000 for Self and Family enrollment) and any rollover funds from prior years must be used first for eligible health care expenses.  Note: The Medical Fund does not reduce the deductible and/or the out-of-pocket maximum.
  • Traditional medical coverage does not begin until you have used your Medical Fund and satisfied your deductible.
  • Prescription drug benefits change to a copayment level once you satisfy your deductible. See section 5(f).
  • In-network medical preventive care is covered at 100% under Section 5 and does not count against your Medical Fund.
  • The Medical Fund provides coverage for both in-network and non-network providers. Under the Traditional medical coverage, in-network benefits apply only when you use a network provider. Out-of-network benefits apply when you do not use a network provider.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.



Benefit Description : Your deductible before Traditional medical coverage beginsCDHP (You pay After the calendar year deductible… )

Once your Medical Fund has been exhausted, you must satisfy your deductible before your Traditional medical coverage begins. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

Once your deductible is satisfied, you will be responsible for your coinsurance amounts for eligible medical expenses until you meet the annual catastrophic out-of-pocket maximum. You also are responsible for copayments for eligible prescriptions.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

100% of allowable charges until you meet the deductible of $1,000 per Self Only enrollment, $2,000 per Self Plus One enrollment, or $2,000 per Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network.




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Your deductible is $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment, and $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.  The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.
  • After you have exhausted your Medical Fund and satisfied your deductible, your Traditional Medical Plan begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



Benefit Description : Diagnostic and treatment servicesCDHP (You pay After the calendar year deductible…)

Professional services of physicians

  • In physician’s office
    • Office medical evaluations, examinations and consultations
    • Second surgical or medical opinion
    • Initial examination of a newborn child covered under a Self Plus One or Self and Family enrollment
  • In an urgent care center
  • During a hospital stay
  • In a skilled nursing facility
  • At home

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : Telehealth servicesCDHP (You pay After the calendar year deductible…)
  • Teladoc consult

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

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

Note: Teladoc is not available for phone service in Idaho (video consults only).

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

In-network:  $40 per consult until the deductible is met, 15% of the $40 consult fee thereafter.

Out-of-network: No benefit. Members must use a Teladoc provider.

Benefit Description : Lab, X-ray and other diagnostic testsCDHP (You pay After the calendar year deductible…)

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap tests
  • Pathology
  • X-rays
  • Non-routine mammograms
  • CT Scans/MRI*
  • Ultrasound
  • Electrocardiogram and electroencephalogram (EEG)

* Note:  CT Scans and MRIs require precertification, see "Services requiring our prior approval" on pages 26-28. 

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

*Note:  Requires precertification.  See "Services requiring our prior approval" on pages 26-28.

In-network:  Nothing at a network provider

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Maternity careCDHP (You pay After the calendar year deductible…)

Complete maternity (obstetrical) care, such as:

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

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

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

Note: Here are some things to keep in mind:

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

You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will cover an extended inpatient stay if medically necessary but you, your representatives, your 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. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury.

Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

In-network: No coinsurance for routine prenatal care or the first postpartum care visit, 15% of our Plan allowance for postpartum care visits thereafter when services are rendered by an in-network delivering health care provider.

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Breastfeeding support, supplies and counseling for each birth

In-network:  Nothing at a network provider.

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:  Home birthsAll charges
Benefit Description : Family planning CDHP (You pay After the calendar year deductible…)

A range of voluntary family planning services limited to:

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

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

In-network:  Nothing for women

For men:

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Reversal of voluntary surgical sterilization, genetic testing and counseling

All charges
Benefit Description : Infertility servicesCDHP (You pay After the calendar year deductible…)

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

In-network: 15% of our Plan allowance, nothing for serum

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All charges
Benefit Description : Treatment therapiesCDHP (You pay After the calendar year deductible…)
  • Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 67.

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

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

Note: We will only cover GHT when we preauthorize the treatment. Call 888-238-6240 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information and it is authorized by Aetna. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Note:  Applied Behavior Analysis (ABA) – Children with autism spectrum disorder is covered under mental health.  (See section 5(e))

 

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

Benefit Description : Physical and occupational therapiesCDHP (You pay After the calendar year deductible…)
  • 60 visits per person, per calendar year for physical or occupational therapy, or a combination of both for the services of each of the following:
    • Qualified Physical therapists
    • Occupational therapists

Note: We only cover therapy when a physician:

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

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

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

Not covered:

  • Long-term rehabilitative therapy
All charges
Benefit Description : Pulmonary and cardiac rehabilitationCDHP (You pay After the calendar year deductible…)
  • 20 visits per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability.
  • Cardiac rehabilitation following angioplasty, cardiovascular surgery, congestive heart failure or a myocardial infarction is provided for up to 3 visits a week for a total of 18 visits.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Long-term rehabilitative therapy

All charges
Benefit Description : Habilitative ServicesCDHP (You pay After the calendar year deductible…)

Habilitative services for congenital or genetic birth defects including, but not limited to, autism or an autism spectrum disorder, and developmental delays. Treatment is provided to enhance the ability to function. Services include occupational therapy, physical therapy and speech therapy.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : Speech therapy CDHP (You pay After the calendar year deductible…)
  • 60 visits per person, per calendar year.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : Hearing services (testing, treatment, and supplies)CDHP (You pay After the calendar year deductible…)
  • Hearing exams for children through age 17 (as shown in Preventive Care, children)
  • One (1) hearing exam every 24 months (See In-network Medical Preventive Care, adult)
  • Audiological testing and medically necessary treatments for hearing problems

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • All other hearing testing and services that are not shown as covered
  • Hearing aids, testing and examinations for them
All charges
Benefit Description : Vision services (testing, treatment, and supplies)CDHP (You pay After the calendar year deductible…)
  • Treatment of eye diseases and injury

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

  • One (1) routine eye exam (including refraction) every 12-month period (See In-Network Medical Preventive Care)

In-network:  Nothing

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

  • Corrective eyeglasses and frames or contact lenses (hard or soft).
Nothing up to your available Medical Fund balance.  All charges if Medical Fund balance is exhausted. Not subject to deductible.

Not Covered:

  • Corrective eyeglasses and frames or contact lenses (except as above) 
  • Fitting of contact lenses
  • Vision therapy, including eye patches and eye exercises, e.g., orthoptics, pleoptics, for the treatment of conditions related to learning disabilities or developmental delays
  • Radial keratotomy and laser eye surgery , including related procedures designed to surgically correct refractive errors
All charges
Benefit Description : Foot careCDHP (You pay After the calendar year deductible…)
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
  • Treatment of weak, strained or flat feet; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open manipulation or fixation)
  • Foot orthotics
  • Podiatric shoe inserts
All charges
Benefit Description : Orthopedic and prosthetic devices CDHP (You pay After the calendar year deductible…)
  • Orthopedic devices such as braces and corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome and prosthetic devices such as artificial limbs and eyes
  • Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
  • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal. See Surgical section 5(b) for coverage of the surgery to insert the device.
  • Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

Note:  Plan lifetime maximum of $500.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Orthopedic and corrective shoes not attached to a covered brace
  • Arch supports
  • Foot orthotics
  • Heel pads and heel cups
  • Lumbosacral supports
  • All charges over $500 for hair prosthesis
All charges
Benefit Description : Durable medical equipment (DME)CDHP (You pay After the calendar year deductible…)

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Contact Plan at 888-238-6240 for specific covered DME.  Some covered items include:

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Home modifications such as stair glides, elevators and wheelchair ramps
  • Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities
  • Elastic stockings and support hose

All charges
Benefit Description : Home health servicesCDHP (You pay After the calendar year deductible…)
  • Home health services ordered by your attending Physician and provided by nurses and home health aides through a home health care agency.  Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist, and services of a home health aide when provided in support of the skilled home health services.  Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less. The Plan will cover up to 60 visits per member per calendar year. Your attending physician will periodically review the program for continuing appropriateness and need.
  • Services include oxygen therapy.

Note: Skilled nursing under Home health services must be precertified by your attending Physician.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Intravenous (IV) Infusion Therapy and medications

In-network: 15% of Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Nursing care for the convenience of the patient or the patient’s family.
  • Transportation
  • Custodial care, i.e., home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative, and appropriate for the active treatment of a condition, illness, disease or injury.
  • Services of a social worker
  • Services provided by a family member or resident in the member’s home.
  • Services rendered at any site other than the member’s home.
  • Services rendered when the member is not homebound because of illness or injury.
  • Private duty nursing services.
All charges
Benefit Description : Chiropractic CDHP (You pay After the calendar year deductible…)
  • Chiropractic - services up to 20 visits per member per calendar year
  • Manipulation of the spine and extremities
  • Adjunctive procedures such as ultrasound, electric muscle stimulation, vibratory therapy and cold pack application

In-network:  15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: 

  • Any services not listed above
All charges
Benefit Description : Alternative medicine treatmentsCDHP (You pay After the calendar year deductible…)

Acupuncture - when provided as anesthesia for covered surgery

Note:  See page 73 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.

In-network:  15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

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

  • Acupuncture other than stated above
  • Applied kinesiology
  • Aromatherapy
  • Biofeedback
  • Craniosacral therapy
  • Hair analysis
  • Reflexology
All charges
Benefit Description : Educational classes and programsCDHP (You pay After the calendar year deductible…)

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

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

To request more information on our disease management programs, call 888-238-6240.

Nothing

Coverage is provided for:

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

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

In-network:  Nothing for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year.  Nothing for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence. 

Out-of-network:  Nothing up to our Plan allowance for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year.  Nothing up to our Plan allowance for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Your deductible is $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment, and $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • After you have exhausted your Medical Fund and satisfied your deductible, your Traditional Medical Plan begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, etc.).
  • YOU OR YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.



Benefit Description : Surgical proceduresCDHP (You pay After the calendar year deductible…)

A comprehensive range of services, such as:

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

 We will consider:

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

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

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

*Subject to medical necessity

** Note: Requires Precertification.  See “Services requiring our prior approval” on pages 26-28. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us.  For precertification or criteria subject to medical necessity, please contact us at 888-238-6240.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

Nothing (no deductible)

Not covered:

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form and for which the disfigurement is not associated with functional impairment, except repair of accidental injury
All charges
Benefit Description : Oral and maxillofacial surgery CDHP (You pay After the calendar year deductible…)

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

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

Note: When requesting oral and maxillofacial services, please check our online provider directory or call Member Services at 888-238-6240 for a participating oral and maxillofacial surgeon.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Dental implants
  • Dental care (such as restorations) involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
All charges
Benefit Description : Organ/tissue transplantsCDHP (You pay After the calendar year deductible…)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  See Other services under You need prior Plan approval for certain services on pages 26-28.

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Blood or marrow stem cell transplants 

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

The Plan extends coverage for the diagnoses as indicated below.

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

*Approved clinical trial necessary for coverage.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

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

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

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

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Clinical trials must meet the following criteria:

A. The member has a current diagnosis that will most likely cause death within one (1) year or less despite therapy with currently accepted treatment; or the member has a diagnosis of cancer; AND

B. All of the following criteria must be met:

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

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

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

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

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

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

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

4. The member must:

a. Not be treated “off protocol,” and

b. Must actually be enrolled in the trial.

In-network:  15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Your deductible is $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment, and $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • After you have exhausted your Medical Fund and satisfied your deductible, your Traditional Medical Plan begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
  • YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.
  • We define observation as monitoring patients following medical or surgical treatments to find out if they need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize (if out-of-network member is responsible to preauthorize inpatient stay). Once admitted, inpatient member cost sharing will apply.



Benefit Description : Inpatient hospitalCDHP (You pay After the calendar year deductible...)

Room and board, such as

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Other hospital services and supplies, such as:

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Whole blood and concentrated red blood cells not replaced by the member
  • Non-covered facilities, such as nursing homes, schools
  • Custodial care, rest cures, domiciliary or convalescent cares
  • Personal comfort items, such as phone and television
  • Private nursing care
All charges
Benefit Description : Outpatient hospital or ambulatory surgical centerCDHP (You pay After the calendar year deductible...)
  • 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.

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

Note:  In-network preventive care services are not subject to coinsurance listed.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Whole blood and concentrated red blood cells not replaced by the member.

All charges

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsCDHP (You pay After the calendar year deductible...)
Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 60-day limit per calendar year when full-time nursing care is necessary and the confinement is medically appropriate as determined by a Plan doctor and approved by the Plan.

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Custodial care All charges
Benefit Description : Hospice careCDHP (You pay After the calendar year deductible...)

Supportive and palliative care for a terminally ill member in the home or hospice facility, including inpatient and outpatient care and family counseling, when provided under the direction of your attending Physician, who certifies the patient is in the terminal stages of illness, with a life expectancy of approximately six (6) months or less

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : AmbulanceCDHP (You pay After the calendar year deductible...)

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

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

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

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

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

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

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

All charges



Section 5(d). Emergency Services/Accidents (CDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Your deductible is $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment, and $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.
  • After you have exhausted your Medical Fund and satisfied your deductible, your Traditional Medical Plan begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • We define observation as monitoring patients following medical or surgical treatments to find out if they need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize (if out-of-network member is responsible to preauthorize inpatient stay). Once admitted, inpatient member cost sharing will apply.



What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.





What to do in case of emergency:  If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world.  An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a pregnant woman, the health of the woman and her unborn child.  If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Aetna as soon as possible.



Benefit Description : Emergency CDHP (You pay After the calendar year deductible…)
  • Emergency or urgent care at a doctor’s office
  • Emergency or urgent care at an urgent care center
  • Emergency care as an outpatient in a hospital, including doctors' services

In-network:  15% of our Plan allowance

Out-of-network:  15% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Elective care or non-emergency care

All charges

Benefit Description : Telehealth servicesCDHP (You pay After the calendar year deductible…)
  • Teladoc consult

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

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

Note: Teladoc is not available for phone service in Idaho (video consult only).

In-network:  $40 per consult until the deductible is met, 15% of the $40 consult fee thereafter.

Out-of-network: No benefit. Members must use a Teladoc provider.

Benefit Description : AmbulanceCDHP (You pay After the calendar year deductible…)

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

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

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

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

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

Note: Air ambulance may be covered. Prior approval is required.

In-network: 15% of our Plan allowance

Out-of-network: 15% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

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

All charges



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

You need to get Plan approval (preauthorization) for certain services.

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • After you have exhausted your Medical Fund and satisfied your deductible, your Traditional Medical Plan begins.
  • Your deductible is $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment, and $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. Benefits are payable only when we determine the care is clinically appropriate to treat your condition. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan. Please see Section 3 of this brochure for a list of services that require preauthorization. 
  • Aetna can assist you in locating participating providers in the Plan, unless your needs for covered
    services extend beyond the capability of the affiliated providers. Emergency care is covered
    (See Section 5(d), Emergency services/accidents). You can receive information regarding the
    appropriate way to access the behavioral health care services that are covered under your specific
    plan by calling Member Services at 888-238-6240. A referral from your PCP is not necessary to
    access behavioral health care but your PCP may assist in coordinating your care.
  • We will provide medical review criteria for denials to enrollees, members or providers upon request or as otherwise required.
  • OPM will base its review of disputes on medically necessary clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.



Benefit Description : Professional servicesCDHP (You pay After the calendar year deductible…)

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

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

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

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

In-network: 15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

  • Telemedicine Behavioral Health consult

In-network: 15% of our Plan allowance

Out-of-network: Not covered

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

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

In-network: 15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : Applied Behavior Analysis (ABA)CDHP (You pay After the calendar year deductible…)

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

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

Note: Requires Precertification. See “Services requiring our prior approval” on pages 26-28. You are responsible for ensuring that we are asked to precertify your care.  You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240.

In-network: 15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : DiagnosticsCDHP (You pay After the calendar year deductible…)

  • Psychological and Neuropsychological testing provided and billed by a licensed mental health and SUD treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

In-network: 15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : Inpatient hospital or other covered facilityCDHP (You pay After the calendar year deductible…)

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

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility

In-network: 15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : Outpatient hospital or other covered facilityCDHP (You pay After the calendar year deductible…)

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

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

In-network: 15% of our Plan allowance

Out-of-network:  40% of our Plan allowance and any difference between our allowance and the billed amount.

Benefit Description : Not coveredCDHP (You pay After the calendar year deductible…)
  • Educational services for treatment of behavioral disorders
  • Services in half-way houses
All charges



Section 5(f). Prescription Drug Benefits (CDHP)

Important things you should keep in mind about these benefits:

  • This is a five tier open formulary pharmacy plan, Advanced Control Formulary. The formulary is a list of drugs that your health plan covers. With your Advanced Control Formulary Pharmacy plan, each drug is grouped as a generic, a brand or a specialty drug.  The preferred drugs within these groups will generally save you money compared to a non-preferred drug.  Each tier has a separate out-of-pocket cost.
    • Preferred generic 
    • Preferred brand
    • Non-preferred generic and brand
    • Preferred specialty
    • Non-preferred specialty
  • We cover prescribed drugs and medications, as described in the chart beginning on the third page.
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • Your deductible is $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment, and $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.
  • Your Medical Fund must be used first for eligible pharmacy expenses and your deductible must be satisfied before your Traditional medical coverage begins. The cost of your prescription will be deducted from your Medical Fund, if available, at the time of the purchase. The cost of your prescription is based on the Aetna contracted rate with network pharmacies. The Aetna contracted rate with the network pharmacy does not reflect or include any rebates Aetna receives from drug manufacturers.
  • Once you exhaust the Medical Fund and satisfy the deductible, you will then pay a copayment at in-network retail pharmacies or the mail-order pharmacy for prescriptions under your Traditional medical coverage. You will pay 40% coinsurance plus the difference between our Plan allowance and the billed amount at out-of-network retail pharmacies. There is no out-of-network mail order pharmacy program.
  • Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. Upon approval by the Plan, the prescription is covered for the current calendar year or a specified time period, whichever is less.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



There are important features you should be aware of which include:

  • Who can write your prescription. A licensed physician or dentist and in states allowing it, licensed/ or certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
  • Where you can obtain them. Any retail pharmacy can be used for up to a 30-day supply. Our mail order program must be utilized for a 31-day up to a 90-day supply of medication (if authorized by your physician). You may obtain up to a 30-day supply of medication for one copay (retail pharmacy), and for a 31-day up to a 90-day supply of medication for two copays (mail order). For retail pharmacy transactions, you must present your Aetna Member ID card at the point of sale for coverage. Please call Member Services at 888-238-6240 for more details on how to use the mail order program. Mail order is not available for drugs and medications ordered through a network Specialty Pharmacy. Prescriptions ordered through a network Specialty Pharmacy are only filled for up to a 30-day supply due to the nature of these prescriptions. If accessing a nonparticipating pharmacy, the member must pay the full cost of the medication at the point of service, then submit a complete paper claim and a receipt for the cost of the prescription to our Direct Member Reimbursement (DMR) unit. Reimbursements are subject to review to determine if the claim meets applicable requirements, and are subject to the terms and conditions of the benefit plan and applicable law.
  • We use a formulary. The formulary is a list of drugs that your Plan covers. Drugs are prescribed by attending licensed doctors and covered in accordance with the 2021 Pharmacy Drug (Formulary) Guide.  Certain drugs require your doctor to get precertification or step therapy from the Plan before they can be covered under the Plan. Your prescription drug plan includes drugs listed in the 2021 Pharmacy Drug (Formulary) Guide. Prescription drugs listed on the formulary exclusions list are excluded unless a medical exception is approved by the Plan. If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at www.aetnafeds.com to review our 2021 Pharmacy Drug (Formulary) Guide or call 888-238-6240.
  • Drugs not on the formulary. Formularies are developed and reviewed by the CVS Caremark Pharmacy and Therapeutics Committee, comprised of physicians, pharmacists and other clinicians that review drugs for inclusion in the formulary. They consider the drug’s effectiveness and safety and cost in their evaluation. While most of the drugs on the non-formulary list are brand drugs, some generic drugs also may be on the non-formulary list. For example, this may happen when brand medications lose their patent and the FDA has granted a period of exclusivity to specific generic manufacturers. When this occurs, the price of the generic drug may not decrease as you might think most generic drugs do. This period of exclusivity usually ranges between 3-6 months. Once this time period expires, competition from other generic manufacturers will generally occur and this helps lower the price of the drug and this may lead the Plan to re-evaluate the generic for possible inclusion on the formulary.  We will place some of these generic drugs that are granted a period of exclusivity on our non-formulary list, which requires the highest copay level. Remember, a generic equivalent will be dispensed, if available, unless your physician specifically requires a brand name and writes "Dispense as Written" (DAW) on the prescription, so discuss this with your doctor.
  • Choose generics. The Plan requires the use of generics if a generic drug is available. If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance* unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained from the Plan. Generics contain the same active ingredients in the same amounts as their brand name counterparts and have been approve by the FDA. By using generic drugs, you will see cost savings, without jeopardizing clinical outcome or compromising quality. *The differential/penalty will not apply to Plan accumulators (example: deductible and out-of-pocket maximum).
  • Precertification. Your pharmacy benefits plan includes our precertification. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-approved by our Pharmacy Management Precertification Unit before they will be covered. Only your physician or pharmacist, in the case of an antibiotic or analgesic, can request prior authorization precertification for a drug. Step-therapy is another type of precertification. Certain medications will be excluded from coverage unless you try one or more "step" drug(s) first, or unless a medical exception is obtained. The drugs requiring precertification or step-therapy are subject to change. Visit our website at www.aetnafeds.com for the most current information regarding the precertification and step-therapy lists. Ask your physician if the drugs being prescribed for you require precertification or step therapy.
  • When to use a participating retail or mail order pharmacy. Covered prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy may be dispensed for up to a 30-day supply. Members must obtain a 31-day up to a 90-day supply of covered prescription medication through mail order (applies to in-network pharmacies only). In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name. Drug costs are calculated based on our contracted rate with the network pharmacy excluding any drug rebates. While mail order is most likely the most cost effective option for most prescriptions, there may be some instances where the most cost effective option for members will be to utilize a retail pharmacy for a 30-day supply versus mail order. Members should utilize the Cost of Care Tool prior to ordering prescriptions through mail order to determine the cost.
  • In the event that a member is called to active military duty and requires coverage under their prescription plan  benefits of an additional filing of their medication(s) prior to departure, their pharmacist will need to contact us. Coverage of additional prescriptions will only be allowed if there are refills remaining on the member's current prescription or a new prescription has been issued by their physician. The member is responsible for the applicable copayment for the additional prescription.
  • The Plan allows coverage of a medication filling when at least 80%of the previous prescription according to the physician’s prescribed directions, has been utilized. For a 30-day supply of medication, this provision would allow a new prescription to be covered on the 24th day, thereby allowing a member to have an additional supply of their medication, in case of emergency.
  • When you do have to file a claim. Send your itemized bill(s) to: Aetna, Pharmacy Management, P.O. Box 52444, Phoenix, AZ 85072-2444.



Here are some things to keep in mind about our prescription drug program:

  • A generic equivalent may be dispensed if it is available, and where allowed by law.
  • Mail order pharmacy. Generally, the drugs available through mail order are maintenance drugs that you take on a regular basis for a chronic or long-term medical condition. Outpatient prescription drugs are covered when dispensed by a network mail order pharmacy or a CVS pharmacy®. Each prescription is limited to a maximum 90-day supply. Prescriptions for less than a 30-day supply or more than a 90-day supply are not eligible for coverage when dispensed by a network mail order pharmacy.

  • Specialty drugs.  Specialty drugs are medications that treat complex, chronic diseases.  Our specialty drug program is called Aetna Specialty Formulary, which includes select oral, injectable and infused medications. The first fill including all subsequent refills of these medications must be obtained through a network specialty pharmacy. 

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

    Often these drugs require special handling, storage and shipping. For a detailed listing of specialty medications, visit www.aetnafeds.com/pharmacy or contact us at 800-537-9384 for a copy. Note that the medications and categories covered are subject to change. Some specialty medications may qualify for third-party copayment assistance programs that could lower your out of-pocket costs for those products. For any such specialty medication where third-party copayment assistance is used, you shall not receive credit toward your out-of-pocket maximum or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate.
  • To request a printed copy of the 2021 Pharmacy Drug (Formulary) Guide, call 888-238-6240. The information in the 2021 Pharmacy Drug (Formulary) Guide is subject to change. As brand name drugs lose their patents and the exclusivity period expires, and new generics become available on the market, the brand name drug may be removed from the formulary. Under your benefit plan, this will result in a savings to you, as you pay a lower prescription copayment for generic formulary drugs. Please visit our website at www.aetnafeds.com for current 2021 Pharmacy Drug (Formulary) Guide information.



Benefit Description : Covered medications and suppliesCDHP (You pay After the calendar year deductible…)
We cover the following medications and supplies prescribed by your licensed attending physician or dentist and obtained from a Plan pharmacy or through our mail order program or an out-of-network retail pharmacy:In-network:
The full cost of the prescription is applied to the deductible before any benefits are considered for payment under the pharmacy plan. Once the deductible is satisfied, the following will apply:
  • Drugs and medicines approved by the U.S. Food and Drug Administration for which a prescription is required by Federal law, except those listed as Not Covered
  • Self-injectable drugs
  • Diabetic supplies limited to:
    • lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips
    • Insulin
    • Disposable needles and syringes for the administration of covered medications
  • Prenatal vitamins (as covered under the Plan’s formulary)

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

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

$10 per covered generic formulary drug;

50% up to $200 maximum per covered brand name formulary drug; and

50% up to $300 maximum per covered non-formulary (generic or brand name) drug.

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

$20 per covered generic formulary drug

50% up to $400 maximum per covered brand name formulary drug; and

50% up to $600 maximum per covered non-formulary (generic or brand name) drug.

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

Women's contraceptive drugs and devices

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

In-network:  Nothing

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

  • Brand name contraceptive drugs
  • Brand name injectable contraceptive drugs such as Depo Provera - five (5) vials per calendar year
  • Brand emergency contraception

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

$10 per covered generic formulary drug;

50% up to $200 maximum per covered brand name formulary drug; and

50% up to $300 maximum per covered non-formulary (generic or brand name) drug.

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

$20 per covered generic formulary drug

50% up to $400 maximum per covered brand name formulary drug; and

50% up to $600 maximum per covered non-formulary (generic or brand name) drug.

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

Specialty Medications

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

Certain Specialty Formulary medications identified on the Specialty Drug list may be covered under the medical or pharmacy section of this brochure. Please refer to page 85, Specialty Drugs for more information or visit: www.aetnafeds.com/pharmacy.

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

Preferred: 50% up to a $350 maximum

Non-preferred: 50% up to $700 maximum

Limited benefits:

  • Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period.  Note: Mail order is not available.

In-network:

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

$10 per covered generic formulary drug;

50% up to $200 maximum per covered brand name formulary drug; and

50% up to $300 maximum per covered non-formulary (generic or brand name) drug.

Out-of-network (retail pharmacies only):

40% plus the difference between our Plan allowance and the billed amount.

Benefit Description : Preventive care medicationsCDHP (You pay After the calendar year deductible…)

Medications to promote better health as recommended by ACA.

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

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

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

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

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

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

In-network:  Nothing

Not covered:

    • Drugs used for the purpose of weight reduction, such as appetite suppressants
    • Drugs for cosmetic purposes, such as Rogaine
    • Drugs to enhance athletic performance
    • Medical supplies such as dressings and antiseptics
    • Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law or covered by the plan
    • Lost, stolen or damaged drugs
    • Vitamins (including prescription vitamins), nutritional supplements not listed as a covered benefit, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition unless otherwise stated
    • Prophylactic drugs including, but no limited to, anti-malarials for travel
    • Fertility drugs
    • Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
    • Compounded thyroid hormone therapy

Note:  Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program.  (See page 63).  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.

All charges



Value Plan Benefits (Value Plan)

See pages 166-167 for a benefits summary.




(Page numbers solely appear in the printed brochure)

Table of Content



Section 5. Value Plan Benefits Overview (Value Plan)

This Plan offers a Value option. Our benefit package is described in this Section. Make sure that you review the benefits that are available under the benefit product in which you are enrolled.

Value Plan Section 5, which describes the Value Plan benefits, is divided into subsections. Please read Important things you should keep in mind about these benefits at the beginning of each subsection. Also read the general exclusions in Section 6; they apply to benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about Value Plan benefits, contact us at 888-238-6240 or on our website at www.aetnafeds.com.

With this Plan, in-network preventive care is covered in full. As you receive other non-preventive medical care, you must meet the Plan’s deductible before we pay benefits according to the benefits described on page 97.




TermDefinition
  • Traditional medical coverage subject to the deductible

After you have paid the Plan’s deductible (In-network: $700 for Self Only enrollment, $1,400 for Self Plus One enrollment and $1,400 for Self and Family enrollment or Out-of-network: $1,400 for Self Only enrollment, $2,800 for Self Plus One enrollment and $2,800 for Self and Family enrollment), we pay benefits under Traditional medical coverage described in Section 5. The Plan typically pays 80% for in-network care and 50% for out-of-network care.

Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductibles for in-network and out-of-network do not cross apply and will need to be met separately for traditional benefits to begin.

Note: Preventive care, PCP/Specialist office visits and Prescription costs are not subject to the annual in-network deductible.

  • Catastrophic protection for out-of-pocket expenses

Your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $6,000 for Self Only, $12,000 for Self Plus One, or $12,000 for Self and Family enrollment in-network and $7,000 for Self Only, $14,000 for Self Plus One, or $14,000 for Self and Family enrollment out-of-network. 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, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-pocket maximum and Value Section 5 Traditional medical coverage subject to the deductible for more details.  In-network and Out-of-network out-of-pocket maximums do not cross apply and will need to be met separately in order for eligible medical expenses to be paid at 100%.

  • Health education resources and account management tools

Connect to www.aetnafeds.com for access to the Aetna Member website, a secure and personalized member site offering you a single source for health and benefits information. Use it to:

  • Perform self-service functions, like checking your deductible balance or the status of a claim.

Aetna Member website gives you direct access to:

  • Care and Costs tools that compare in-network and out-of-network provider fees, the cost of brand-name drugs vs. their generic equivalents, and the costs for services such as routine physicals, emergency room visits, lab tests, X-rays, MRIs, etc.
  • Real-time, out-of-pocket estimates for medical expenses based on your Aetna health plan.  You can compare the cost of doctors and facilities before you make an appointment, helping you budget for and manage health care expenses.
  • A hospital comparison tool that allows you to see how hospitals in your area rank on measures important to your care.
  • Our online provider directory.
  • Online customer service that allows you to request member ID cards, send secure messages to Member Services, and more.
  • Tools and resources to help you manage your health with access to your health assessment, digital coaching, personal health record, and more.
  • Health Incentive Credit and Biometric Screening Incentive

Health Incentive Credit: The Plan will provide a health incentive credit of up to $200 for Self Only, $400 for Self Plus One or $400 for Self and Family for completing any combination of the activities listed below.  Each activity below allows a member to earn a $50 credit for completion, up to the maximum incentive credit of $200 for Self Only, $400 for Self Plus One or $400 for Self and Family.

  • Online health risk assessment and one online wellness program (incentive credit only available to enrollee and spouse)
  • Routine mammogram
  • Well adult preventive care (includes well adult visits, Prostate Specific Antigen (PSA) test, routine hearing exam and routine X-ray)
  • Well baby/well child preventive care
  • Immunizations
  • Flu Shot
  • Well woman preventive care (includes routine Ob/Gyn and routine Pap/Radiologist/Pathologist and Lab)
  • Routine eye exam

All services listed above must be covered services and can be subject to frequency limitations.

Biometric Screening Incentive: (Available February 1st - December 31st due to tracking requirements) The Plan will provide a health incentive credit for an enrollee and/or spouse (over 18 years of age) who complete a biometric screening.  Biometric screenings must include total cholesterol, HDL, calculated LDL, calculated cholesterol/HDL ratio, triglycerides and glucose, blood pressure, and waist circumference.

Members obtain the screening at a Quest Diagnostics Patient Service Center (PSC).  If you are not located within 20 miles of a Quest Diagnostics PSC, you may send the appropriate form to your physician's office, and request that your physician complete the form and fax or mail it back to Quest. Visit www.aetnafeds.com for information on setting up an appointment at a Quest PSC or to obtain the form if you are not located within 20 miles of a Quest PSC. The biometric screening incentive is separate from the health incentive credit the Plan offers for completion of wellness activities. 

The Plan will provide a credit of $50 per enrollee and/or spouse, up to an annual family limit of $100 upon completion of the biometric screening.

Visit www.aetnafeds.com for information on setting up an appointment at a Quest PSC or to obtain the form if you are not located within 20 miles of a Quest PSC.

Credits earned from the Health Incentive Credit and Biometric Screening Incentive will offset future claims.  Any new claims submitted after credits are earned will be paid first with any accumulated credits.  The incentive credit will offset the deductible and coinsurance, not any other kind of member responsibility (such as copays).  Credits also cannot be used toward pharmacy copays or coinsurance.

The following is an example of how the credits would work:

A member completes two of the activities above and earns $100 in credits.  The member then receives services and the charge is $67.  The member has not yet met their deductible.  The provider will submit the claim to Aetna and Aetna would pay the $67 using the member's credit.  Member would owe nothing to the provider and would still have a $33 credit to use toward another claim.  The $67 would still apply to the member's deductible.  Any unused credits carry over year to year as long as the member continues in that plan.




Section 5. Medical Preventive Care (Value Plan)

Important things you should keep in mind about these medical preventive care benefits:

  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Preventive care is health care services designed for prevention and early detection of illness in average risk, people without symptoms, generally including routine physical examinations, tests and immunizations.  We follow the U.S. Preventive Services Task Force recommendations for preventive care unless noted otherwise.  For more information visit www.aetnafeds.com.
  • The Plan pays 100% for the medical preventive care services listed in this Section as long as you use a network provider.
  • If you choose to access preventive care from a non-network provider, you will not qualify for 100% preventive care coverage. Please see Section 5 – Traditional medical coverage subject to the deductible.
  • For preventive care not listed in this Section, preventive care from a non-network provider, or any other covered expenses, please see Section 5 – Traditional medical coverage subject to the deductible.



Benefit Description : Medical Preventive Care, adultValue (You pay)
  • Routine physicals - one (1) exam every calendar year

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

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

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 50% of our Plan allowance and any difference between our allowance and the billed amount.

  •  Routine mammogram - covered for women
    • One (1) every calendar year; or when medically necessary

 

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 50% of our Plan allowance and any difference between our allowance and the billed amount.

  • Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.
     
    • The following exams limited to:
      • One (1) routine eye exam every 12 months

Note: Some tests provided during a routine physical may not be considered preventive. Contact Member Services at 888-238-6240 for information on whether a specific test is considered routine.

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

In-network: Nothing at a network provider.

Out-of-network: All charges until you satisfy your deductible, then 50% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

All charges

Benefit Description : Medical Preventive Care, childrenValue (You pay)
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org.
  • Well-child care charges for routine examinations, immunizations and care (up to age 22)
    • Seven (7) routine exams from birth to age 12 months
    • Three (3) routine exams from age 12 months to 24 months
    • Three (3) routine exams from age 24 months to 36 months
    • One (1) routine exam per year thereafter to age 22
  • Hearing loss screening of newborns provided by a participating hospital before discharge
  • One (1) routine eye exam every 12 months through age 17 to determine the need for vision correction
  • One (1) routine hearing exam every 24 months through age 17 to determine the need for hearing correction

Note: Some tests provided during a routine physical may not be considered preventive. Contact Member Services at 888-238-6240 for information on whether a specific test is considered routine.

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

In-network: Nothing at a network provider

Out-of-network: All charges until you satisfy your deductible, then 50% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Physical exams, immunizations and boosters required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams or travel.

All charges




Section 5. Traditional Medical Coverage Subject to the Deductible (Value Plan)

Important things you should keep in mind about these benefits:

  • Traditional medical coverage does not begin to pay until you have satisfied your deductible.
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • In-network medical preventive care is covered at 100% (see pages 94-96) and is not subject to your calendar year deductible.
  • The deductible is: In-network - $700 for Self Only enrollment, $1,400 for a Self Plus One enrollment and $1,400 for Self and Family enrollment and Out-of-network $1,400 for a Self Only enrollment, $2,800 for a Self Plus One, and $2,800 for a Self and Family enrollment. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. You must satisfy your deductible before your Traditional medical coverage may begin. Note: Preventive care, PCP/Specialist office visits and Prescription costs are not subject to the annual in-network deductible.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.
  • Under Traditional medical coverage, in-network benefits apply only when you use a network provider. Out-of-network benefits apply when you do not use a network provider. Your dollars will generally go further when you use network providers because network providers agree to discount their fees.
  • Whether you use network or non-network providers, you are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After your coinsurance, copayments and deductibles total $6,000 for Self Only enrollment, $12,000 for Self Plus One, or $12,000 for Self and Family enrollment in-network or $7,000 for Self Only enrollment, $14,000 for Self Plus One, or $14,000 for Self and Family enrollment out-of-network in any calendar year, you do not have to pay any more for covered services from network or non-network providers. 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, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s benefit maximum, or if you use out-of-network providers, amounts in excess of the Plan allowance).
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



Benefit Description : Deductible before Traditional medical coverage beginsValue (You pay )

You must satisfy your deductible before your Traditional medical coverage begins. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

Once your Traditional medical coverage begins, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions, until you reach the annual catastrophic protection out-of-pocket maximum. At that point, we pay eligible medical expenses for the remainder of the calendar year at 100%.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.

100% of allowable charges until you meet the deductible:

In-network: $700 for Self Only enrollment, $1,400 for Self Plus One enrollment, and $1,400 for Self and Family enrollment

Out-of-Network: $1,400 per Self Only enrollment, $2,800 for Self Plus One enrollment, or $2,800 per Self and Family enrollment




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is: In-network - $700 for Self Only enrollment, $1,400 for Self Plus One enrollment, and $1,400 for Self and Family enrollment or Out-of-Network - $1,400 for Self Only enrollment, $2,800 for Self Plus One enrollment, and $2,800 for Self and Family enrollment each calendar year.  Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.  Note: PCP office visits and Specialist office visits are not subject to the annual in-network deductible. 
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



Benefit Description : Diagnostic and treatment servicesValue (You pay After the calendar year deductible… )

Professional services of physicians

  • In physician’s office
    • Office medical evaluations, examinations and consultations
    • Second surgical or medical opinion
    • Initial examination of a newborn child covered under a Self Plus One or Self and Family enrollment
  • In an urgent care center
  • During a hospital stay
  • In a skilled nursing facility
  • At home

In-network: $25 Primary Care Physician (PCP) visit, $40 per specialist visit (No deductible)

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

Benefit Description : Telehealth servicesValue (You pay After the calendar year deductible… )
  • Teladoc consult

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

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

Note: Teladoc is not available for phone service in Idaho (video consults only).

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

In-network: $40 per consult (No deductible)

Out-of-network: No benefit. Members must use a Teladoc provider.

Benefit Description : Lab, X-ray and other diagnostic testsValue (You pay After the calendar year deductible… )

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap tests
  • Pathology
  • X-rays
  • Non-routine mammograms
  • CT Scans/MRI*
  • Ultrasound
  • Electrocardiogram and electroencephalogram (EEG)

 Note: See Section 5(c) for cost sharing for these services not performed in a doctor's office.

*Note: CT Scans and MRIs require precertification see "Services requiring our prior approval" on pages 26-28.

Provided in Office Visit:

In-network: $25 PCP visit, $40 per specialist visit (No deductible)

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

Radiology center, Diagnostic centers or MRI centers:

In-network: 20% of plan allowance (No deductible)

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

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

*Note: Requires precertification. See "Services requiring our prior approval" on pages 26-28.

In-network: Nothing at a network provider

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

Benefit Description : Maternity careValue (You pay After the calendar year deductible… )
  • Complete maternity (obstetrical) care, such as:
  • Routine Prenatal care - includes the initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery.

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

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

Note: Here are some things to keep in mind:

  • You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
  • You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will cover an extended inpatient stay if medically necessary but you, your representatives, your doctor, or your hospital must recertify the extended stay.
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
  • See Hospital benefits (Section 5c) no member cost sharing (deductible and coinsurance) for in-network inpatient maternity care and Surgery benefits (Section 5b).

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

In-network: No coinsurance for routine prenatal care or the first postpartum care visit, $25 for PCP visit or $40 for specialist visit for postpartum care visits thereafter when services are rendered by an in-network delivering health care provider. (No deductible)

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

Breastfeeding support, supplies and counseling for each birth

In-network: Nothing at Network Provider

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

Not covered:  Home birthsAll charges
Benefit Description : Family planning Value (You pay After the calendar year deductible… )

A range of voluntary family planning services limited to:

  • Contraceptive counseling on an annual basis
  • Voluntary sterilization (See Surgical procedures (Section 5b)
  • Surgically implanted contraceptives
  • Generic injectable contraceptive drugs, such as Depo-Provera
  • Intrauterine devices (IUDs)
  • Diaphragms

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

 

 

In-network:  Nothing for women

For men: (No deductible)

$25 per PCP visit

$40 for Specialist visit

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

Not covered:

  • Reversal of voluntary surgical sterilization
  • Genetic testing counseling
All charges
Benefit Description : Infertility servicesValue (You pay After the calendar year deductible… )

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

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

In-network: $25 PCP visit, $40 per specialist visit (No deductible)

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

Not covered:

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

In-network: $25 PCP visit, $40 per specialist visit, nothing for serum (No deductible)

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

Not covered: Provocative food testing and sublingual allergy desensitization

All charges
Benefit Description : Treatment therapiesValue (You pay After the calendar year deductible… )
  • Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 113.

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

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

Note: We will only cover GHT when we preauthorize the treatment. Call 888-238-6240 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information and it is authorized by Aetna. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Note:  Applied Behavior Analysis (ABA) - Children with autism spectrum disorder is covered under mental health.  (See section 5(e))

In-network: $40 per visit (No deductible)

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

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

Benefit Description : Physical and occupational therapies Value (You pay After the calendar year deductible… )

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

  • Qualified Physical therapists
  • Occupational therapists

Note: We only cover therapy when a physician:

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

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

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

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

In-network: $25 PCP visit, $40 per specialist visit (No deductible)

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

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

Not covered:

  • Long-term rehabilitative therapy
All charges
Benefit Description : Pulmonary and cardiac rehabilitationValue (You pay After the calendar year deductible… )
  • 20 visits per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability.
  • Cardiac rehabilitation following angioplasty, cardiovascular surgery, congestive heart failure or a myocardial infarction is provided for up to three (3) visits a week for a total of 18 visits.

In-network: $25 PCP visit, $40 per specialist visit (No deductible)

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

Not covered: Long-term rehabilitative therapy All charges
Benefit Description : Habilitative ServicesValue (You pay After the calendar year deductible… )

Habilitative services for congenital or genetic birth defects including, but not limited to, autism or an autism spectrum disorder, and developmental delays. Treatment is provided to enhance the ability to function. Services include occupational therapy, physical therapy and speech therapy.

In-network: 20% of our Plan allowance (No deductible)

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

Benefit Description : Speech therapy Value (You pay After the calendar year deductible… )
  • 60 visits per person, per calendar year.

In-network: $25 PCP visit, $40 per specialist visit (No deductible)

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

Benefit Description : Hearing services (testing, treatment, and supplies)Value (You pay After the calendar year deductible… )
  • Hearing exams for children through age 17 (as shown in Preventive Care, children)
  • One (1) hearing exam every 24 months for adults
  • Audiological testing and medically necessary treatments for hearing problems. 

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

In-network: $25 PCP visit, $40 per specialist visit (No deductible)

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

Not covered:

  • All other hearing testing and services that are not shown as covered
  • Hearing aids, testing and examinations for them
All charges
Benefit Description : Vision services (testing, treatment, and supplies)Value (You pay After the calendar year deductible… )
  • Treatment of eye diseases and injury

In-network: $25 PCP visit, $40 per specialist visit (No deductible)

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

One (1) routine eye exam (including refraction) every 12-month period         (See In-Network Medical Preventive Care)

In-network: Nothing

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

Not covered:

  • Fitting of contact lenses
  • Vision therapy, including eye patches and eye exercises, e.g., orthoptics, pleoptics, for the treatment of conditions related to learning disabilities or developmental delays
  • Radial keratotomy and laser eye surgery, including related procedures designed to surgically correct refractive errors
All charges
Benefit Description : Foot care Value (You pay After the calendar year deductible… )
  • Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

In-network: $25 PCP visit, $40 per specialist visit (No deductible)

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

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,     except as stated above
  • Treatment of weak, strained or flat feet; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open manipulation or fixation)
  • Foot orthotics
  • Podiatric shoe inserts
All charges
Benefit Description : Orthopedic and prosthetic devices Value (You pay After the calendar year deductible… )
  • Orthopedic devices such as braces and corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome and prosthetic devices such as artificial limbs and eyes
  • Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
  • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator and surgically implanted breast implant following mastectomy, and lenses following cataract removal. See Section 5(b) for coverage of the surgery to insert the device.
  • Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

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

In-network: 20% of our Plan allowance

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

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

Note:  Plan lifetime maximum of $500.

In-network: 20% of our Plan allowance

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

Not covered:

  • Orthopedic and corrective shoes not attached to a covered brace
  • Arch supports
  • Foot orthotics
  • Heel pads and heel cups
  • Podiatric shoe inserts
  • Lumbosacral supports
  • All charges over $500 for hair prosthesis
All charges
Benefit Description : Durable medical equipment (DME)Value (You pay After the calendar year deductible… )

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Contact Plan at 888-238-6240 for specific covered DME.  Some covered items include:

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

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

In-network: 20% of our Plan allowance

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

Not covered:

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

Note: Skilled nursing under Home health services must be precertified by your attending Physician.

In-network: 20% of our Plan allowance

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

Intravenous (IV) Infusion Therapy and medications

In-network: $40 per visit (no deductible)

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

Not covered:

  • Nursing care for the convenience of the patient or the patient’s family
  • Transportation
  • Custodial care, i.e., home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative and appropriate for the active treatment of a condition, illness, disease, or injury
  • Services of a social worker
  • Services provided by a family member or resident in the member’s home
  • Services rendered at any site other than the member’s home
  • Services rendered when the member is not homebound because of illness or injury
  • Private duty nursing services
All charges
Benefit Description : Chiropractic Value (You pay After the calendar year deductible… )
See Alternative Medicine TreatmentsAll charges above benefits shown in Alternative Medicine Treatments.
Benefit Description : Alternative medicine treatmentsValue (You pay After the calendar year deductible… )

Chiropractic and Acupuncture - 20 visits per person per calendar year for chiropractic or acupuncture or a combination of both

Acupuncture - when provided as anesthesia for covered surgery

Note: See page 119 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.

In-network: 20% of our Plan allowance (No deductible)

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

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

  • Acupuncture other than stated above
  • Applied kinesiology
  • Aromatherapy
  • Biofeedback
  • Craniosacral therapy
  • Hair analysis
  • Reflexology
All charges
Benefit Description : Educational classes and programsValue (You pay After the calendar year deductible… )

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

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

To request more information on our disease management programs, call 888-238-6240.

Nothing

Coverage is provided for:

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

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

In-network:Nothing for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year. Nothing for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.

Out-of-network: Nothing up to our Plan allowance for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year. Nothing up to our Plan allowance for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is: In-network - $700 for Self Only enrollment, $1,400 for Self Plus One enrollment, and $1,400 for Self and Family enrollment or Out-of-Network - $1,400 for Self Only enrollment, $2,800 for Self Plus One enrollment, and $2,800 for Self and Family enrollment each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.  Note: PCP office visits and Specialist office visits are not subject to the annual in-network deductible. 
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, etc.).
  • YOU OR YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.



Benefit Description : Surgical proceduresValue (You pay After the calendar year deductible… )

A comprehensive range of services, such as:

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

We will consider:

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

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

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

* Subject to medical necessity
** Note: Requires Precertification. See “Services requiring our prior approval” on pages 26-28. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240.

In-network: 20% of our Plan allowance

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

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

Nothing (no deductible)

Not covered:

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

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

In-network: 20% of our Plan allowance

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

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form and for which the disfigurement is not associated with functional impairment, except repair of accidental injury
All charges
Benefit Description : Oral and maxillofacial surgery Value (You pay After the calendar year deductible… )

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

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

Note: When requesting oral and maxillofacial services, please check our online provider directory or call Member Services at 888-238-6240 for a participating oral and maxillofacial surgeon.

In-network: 20% of our Plan allowance

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

Not covered:

  • Dental implants
  • Dental care (such as restorations) involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
All charges
Benefit Description : Organ/tissue transplantsValue (You pay After the calendar year deductible… )

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on pages 26-28.

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

In-network: 20% of our Plan allowance

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

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

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

In-network: 20% of our Plan allowance

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

Blood or marrow stem cell transplants

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

The Plan extends coverage for the diagnoses as indicated below.

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

*Approved clinical trial necessary for coverage.

In-network: 20% of our Plan allowance

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

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

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

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

In network: 20% of our Plan allowance

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

 

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

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

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

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

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

In-network: 20% of our Plan allowance

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

Clinical trials must meet the following criteria:

A. The member has a current diagnosis that will most likely cause death within one (1) year or less despite therapy with currently accepted treatment; or the member has a diagnosis of cancer; AND

B. All of the following criteria must be met:

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

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

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

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

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

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

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

4. The member must:

a. Not be treated “off protocol,” and

b. Must actually be enrolled in the trial.

In-network: 20% of our Plan allowance

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

Not covered:

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

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

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

In-network: 20% of our Plan allowance

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




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is: In-network - $700 for Self Only enrollment, $1,400 for Self Plus One enrollment, and $1,400 for Self and Family enrollment or Out-of-Network - 1,400 for Self Only enrollment, $2,800 for Self Plus One enrollment, and $2,800 for Self and Family enrollment each calendar year.  Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.  Note: PCP office visits and Specialist office visits are not subject to the annual in-network deductible. 
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge    (i.e., physicians, etc.) are in Sections 5(a) or (b).
  • YOUR NETWORK PHYSICIAN MUST PRECERTIFY HOSPITAL STAYS FOR IN-NETWORK FACILITY CARE; YOU MUST PRECERTIFY HOSPITAL STAYS FOR NON-NETWORK FACILITY CARE; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY FOR NON-NETWORK FACILITY CARE. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.
  • We define observation as monitoring patients following medical or surgical treatments to find out if they need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize (if out-of-network member is responsible to preauthorize inpatient stay). Once admitted, inpatient member cost sharing will apply.



Benefit Description : Inpatient hospitalValue (You Pay After the calendar year deductible...)

Room and board, such as

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

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

In-network: 20% of our Plan allowance

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

Inpatient maternity services

In-network: 20% of our Plan allowance

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

Other hospital services and supplies, such as:

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

In-network: 20% of our Plan allowance

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

Not covered:

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

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

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

Note:  In-network preventive care services are not subject to coinsurance listed.

In-network: 20% of our Plan allowance

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

Radiology center, Diagnostic centers or MRI centers:

In-network: 20% of plan allowance (No deductible) Out-of-network: 50% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Whole blood and concentrated red blood cells not replaced by the member.

All charges
Benefit Description : Extended care benefits/Skilled nursing care facility benefitsValue (You Pay After the calendar year deductible...)
Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 60-day limit per calendar year when full-time nursing care is necessary and the confinement is medically appropriate as determined by a Plan doctor and approved by the Plan.

In-network: 20% of our Plan allowance

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

Not covered: Custodial care All charges
Benefit Description : Hospice careValue (You Pay After the calendar year deductible...)

Supportive and palliative care for a terminally ill member in the home or hospice facility, including inpatient and outpatient care and family counseling, when provided under the direction of your attending Physician, who certifies the patient is in the terminal stages of illness, with a life expectancy of approximately six (6) months or less.

In-network: 20% of our Plan allowance

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

Benefit Description : AmbulanceValue (You Pay After the calendar year deductible...)

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

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

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

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

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

In-network: 20% of our Plan allowance

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

Not covered:

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

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

All charges



Section 5(d). Emergency Services/Accidents (Value Plan)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is: In-network - $700 for Self Only enrollment, $1,400 for Self Plus One enrollment, and $1,400 for Self and Family enrollment or Out-of-Network - $1,400 for Self Only enrollment, $2,800 for Self Plus One enrollment, and $2,800 for Self and Family enrollment each calendar year.  Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.  Note: PCP office visits and Specialist office visits are not subject to the annual in-network deductible. 
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • We define observation as monitoring patients following medical or surgical treatments to find out if they need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize (if out-of-network member is responsible to preauthorize inpatient stay). Once admitted, inpatient member cost sharing will apply.



What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.


What to do in case of emergency:

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person’s health, or with respect to a pregnant woman, the health of the woman and her unborn child. If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Aetna as soon as possible.




Benefit Description : Emergency Value (You pay After the calendar year deductible… )
  • Emergency or urgent care at a doctor’s office
  • Emergency or urgent care at an urgent care center
  • Emergency care as an outpatient in a hospital, including doctors' services

In-network: 20% of our Plan allowance

Out-of-network: 20% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered: Elective or non-emergency care

All charges
Benefit Description : Telehealth servicesValue (You pay After the calendar year deductible… )
  • Teladoc consult

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

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

Note: Teladoc is not available for phone service in Idaho (video consult only).

In-network: $40 per consult (No deductible)

Out-of-network: No benefit. Members must use a Teladoc provider.

Benefit Description : AmbulanceValue (You pay After the calendar year deductible… )

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

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

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

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

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

Note: Air ambulance may be covered. Prior approval is required.

In-network: 20% of our Plan allowance

Out-of-network: 20% of our Plan allowance and any difference between our allowance and the billed amount.

Not covered:

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

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

All charges



Section 5(e). Mental Health and Substance Use Disorder Benefits (Value Plan)

You need to get Plan approval (preauthorization) for certain services.

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • The deductible is: In-network - $700 for Self Only enrollment, $1,400 for Self Plus One enrollment, and $1,400 for Self and Family enrollment or Out-of-Network - $1,400 for Self Only enrollment, $2,800 for Self Plus One enrollment, and $2,800 for Self and Family enrollment each calendar year.  Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.  In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin.  Note: PCP office visits and Specialist office visits are not subject to the annual in-network deductible. 
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. Benefits are payable only when we determine the care is clinically appropriate to treat your condition. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan. Please see Section 3 of this brochure for a list of services that require preauthorization.
  • Aetna can assist you in locating participating providers in the Plan, unless your needs for covered services extend beyond the capability of the affiliated providers. Emergency care is covered (See Section 5(d), Emergency services/accidents). You can receive information regarding the appropriate way to access the behavioral health care services that are covered under your specific plan by calling member Services at 888-238-6240. A referral from your PCP is not necessary to access behavioral health care but your PCP may assist in coordinating your care.
  • We will provide medical review criteria for denials to enrollees, members or providers upon request or as otherwise required.
  • OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.




Benefit Description : Professional servicesValue (You pay After the calendar year deductible… )

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

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

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

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

In-network: $40 per visit (No deductible)

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

  • Telemedicine Behavioral Health consult

In-network: $40 per visit (No deductible)

Out-of-network:  Not covered

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

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

In-network: $40 per visit (No deductible)

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

Benefit Description : Applied Behavior Analysis (ABA)Value (You pay After the calendar year deductible… )

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

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

Note: Requires Precertification. See “Services requiring our prior approval” on pages 26-28. You are responsible for ensuring that we are asked to precertify your care.  You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240.

In-network: 20% of our plan allowance (No deductible)

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

Benefit Description : DiagnosticsValue (You pay After the calendar year deductible… )

  • Psychological and Neuropsychological testing provided and billed by a licensed mental health and SUD treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

In-network: 20% of our plan allowance (No deductible)

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

Benefit Description : Inpatient hospital or other covered facilityValue (You pay After the calendar year deductible… )

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

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility

In-network: 20% of our Plan allowance

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

Benefit Description : Outpatient hospital or other covered facilityValue (You pay After the calendar year deductible… )

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

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

In-network: 20% of plan allowance (No deductible)

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

Benefit Description : Not coveredValue (You pay After the calendar year deductible… )
  • Educational services for treatment of behavioral disorders
  • Services in half-way houses
All charges



Section 5(f). Prescription Drug Benefits (Value Plan)

Important things you should keep in mind about these benefits:

  • This is a five tier open formulary pharmacy plan, Advanced Control Formulary. The formulary is a list of generic and brand-name drugs that your health plan covers.  With your Advanced Control Formulary Pharmacy plan, each drug is grouped as a generic, a brand or a specialty drug.  The preferred drugs within these groups will generally save you money compared to a non-preferred drug.  Each tier has a separate out-of-pocket cost.
    • Preferred generic
    • Preferred brand
    • Non-preferred generic and brand
    • Preferred specialty
    • Non-preferred specialty
  • We cover prescribed drugs and medications, as described in the chart beginning on the third page. Copayment/coinsurance levels reflect in-network pharmacies only. If you obtain your prescription at an out-of-network pharmacy (non-preferred), you will be reimbursed at our Plan allowance less 50%. You are responsible for any difference between our Plan allowance and the billed amount.
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • For prescription drugs and medications, In-network: Deductible does not apply. Out-of-Network: You must first satisfy your deductible. Out-of-Network: $1,400 for Self Only enrollment, $2,800 for Self Plus One enrollment, and $2,800 for Self and Family enrollment each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The out-of-network deductible applies to all out-of-network benefits in this Section. The cost of your prescription is based on the Aetna contracted rate with network pharmacies. The Aetna contracted rate with the network pharmacy does not reflect or include any rebates Aetna receives from drug manufacturers.
  • In-network, you will pay a copayment or coinsurance at in-network retail pharmacies or the mail-order pharmacy for prescriptions under your Traditional medical coverage. Out-of-network, once you satisfy the deductible you will pay 50% coinsurance plus the difference between our Plan allowance and the billed amount at out-of-network retail pharmacies. There is no out-of-network mail order pharmacy program.
  • Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. Upon approval by the Plan, the prescription is covered for the current calendar year or a specified time period, whichever is less.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



There are important features you should be aware of which include:

  • Who can write your prescription. A licensed physician or dentist or, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
  • Where you can obtain them. Any retail pharmacy can be used for up to a 30-day supply. Our mail order program must be utilized for a 31-day up to a 90-day supply of medication (if authorized by your physician). You may obtain up to a 30-day supply of medication for one copay (retail pharmacy), and for a 31-day up to a 90-day supply of medication for two copays (mail order). For retail pharmacy transactions, you must present your Aetna Member ID card at the point of sale for coverage. Please call Member Services at 888-238-6240 for more details on how to use the mail order program. Mail order is not available for drugs and medications ordered through a network Specialty Pharmacy. Prescriptions ordered through a network Specialty Pharmacy are only filled for up to a 30-day supply due to the nature of these prescriptions. If accessing a nonparticipating pharmacy, the member must pay the full cost of the medication at the point of service, then submit a complete paper claim and a receipt for the cost of the prescription to our Direct Member Reimbursement (DMR) unit. Reimbursements are subject to review to determine if the claim meets applicable requirements, and are subject to the terms and conditions of the benefit plan and applicable law.
  • We use a formulary. The formulary is a list of drugs that your Plan covers. Drugs are prescribed by attending licensed doctors and covered in accordance with the 2021 Pharmacy Drug (Formulary) Guide.  Certain drugs require your doctor to get precertification or step therapy from the Plan before they can be covered under the Plan. Your prescription drug plan includes drugs listed in the 2021 Pharmacy Drug (Formulary) Guide. Prescription drugs listed on the formulary exclusions list are excluded unless a medical exception is approved by us the Plan. If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at www.aetnafeds.com/pharmacy to review our 2021 Pharmacy Drug (Formulary) Guide or call 888-238-6240.
  • Drugs not on the formulary. Formularies are developed and reviewed by the CVS Caremark Pharmacy and Therapeutics Committee, comprised of physicians, pharmacists and other clinicians that review drugs for inclusion in the formulary. They consider the drug’s effectiveness and safety and cost in their evaluation. While most of the drugs on the non-formulary list are brand drugs, some generic drugs also may be on the non-formulary list. For example, this may happen when brand medications lose their patent and the FDA has granted a period of exclusivity to specific generic manufacturers. When this occurs, the price of the generic drug may not decrease as you might think most generic drugs do. This period of exclusivity usually ranges between 3-6 months. Once this time period expires, competition from other generic manufacturers will generally occur and this helps lower the price of the drug and this may lead the Plan to re-evaluate the generic for possible inclusion on the formulary. We will place some of these generic drugs that are granted a period of exclusivity on our non-formulary list, which requires the highest copay level.
  • Choose generics. The Plan requires the use of generics if a generic drug is available. If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance* unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained from the Plan. Generics contain the same active ingredients in the same amounts as their brand name counterparts and have been approved by the FDA. By using generic drugs, you will see cost savings, without jeopardizing clinical outcome or compromising quality. *The differential/penalty will not apply to Plan accumulators (example: deductible and out-of-pocket maximum).
  • Precertification. Your pharmacy benefits plan includes precertification. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-approved by our Pharmacy Management Precertification Unit before they will be covered. Only your physician or pharmacist, in the case of an antibiotic or analgesic, can request precertification for a drug. Step-therapy is another type of precertification. Certain medications will be excluded from coverage unless you try one or more "step" drug(s) first, or unless a medical exception is obtained. The drugs requiring precertification or step-therapy are subject to change. Visit our website at www.aetnafeds.com for the most current information regarding the precertification and step-therapy lists. Ask your physician if the drugs being prescribed for you require precertification or step therapy.
  • When to use a participating retail or mail order pharmacy. Covered prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy may be dispensed for up to a 30-day supply. Members must obtain a 31-day up to a 90-day supply of covered prescription medication through mail order. In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available. (See choose generics above) Drug costs are calculated based on our contracted rate with the network pharmacy excluding any drug rebates. While mail order is most likely the most cost effective option for most prescriptions, there may be some instances where the most cost effective option for members will be to utilize a retail pharmacy for a 30-day supply versus mail order. Members should utilize the Cost of Care Tool on Aetna Member website prior to ordering prescriptions through mail order to determine the cost.

    In the event that a member is called to active military duty and requires coverage under their prescription plan
    benefits of an additional filing of their medication(s) prior to departure, their pharmacist will need to contact us. Coverage of additional prescriptions will only be allowed if there are refills remaining on the member's current prescription or a new prescription has been issued by their physician. The member is responsible for the applicable copayment for the additional prescription.
  • The Plan allows coverage of a medication filling when at least 80% of the previous prescription according to the physician’s prescribed directions, has been utilized. For a 30-day supply of medication, this provision would allow a new prescription to be covered on the 24th day, thereby allowing a member to have an additional supply of their medication, in case of emergency.
  • When you do have to file a claim. Send your itemized bill(s) to: Aetna, Pharmacy Management, P.O. Box 52444, Phoenix, AZ 85072-2444.



Here are some things to keep in mind about our prescription drug program:

  • A generic equivalent may be dispensed if it is available, and where allowed by law.
  • Mail order pharmacy. Generally, the drugs available through mail order are maintenance drugs that you take on a regular basis for a chronic or long-term medical condition. Outpatient prescription drugs are covered when dispensed by a network mail order pharmacy or a CVS pharmacy®. Each prescription is limited to a maximum 90-day supply. Prescriptions for less than a 30-day supply or more than a 90-day supply are not eligible for coverage when dispensed by a network mail order pharmacy.

  • Specialty drugs. Specialty drugs are medications that treat complex, chronic diseases which includes select oral, injectable and infused medications.  The first fill including all subsequent refills of these medications must be obtained through a network specialty pharmacy.

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

    Often these drugs require special handling, storage and shipping. For a detailed listing of specialty medications visit www.aetnafeds.com/pharmacy or contact us at 800-537-9384 for a copy. Note that the medications and categories covered are subject to change. Some specialty medications may qualify for third-party copayment assistance programs that could lower your out of-pocket costs for those products. For any such specialty medication where third-party copayment assistance is used, you shall not receive credit toward your out-of-pocket maximum or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate.
  • To request a printed copy of the 2021 Pharmacy Drug (Formulary) Guide, call 888-238-6240. The information in the 2021 Pharmacy Drug (Formulary) Guide is subject to change. As brand name drugs lose their patents and the exclusivity period expires, and new generics become available on the market, the brand name drug may be removed from the formulary. Under your benefit plan, this will result in a savings to you, as you pay a lower prescription copayment for generic formulary drugs. Please visit our website at www.aetnafeds.com for current 2021 Pharmacy Drug (Formulary) Guide information.



Benefit Description : Covered medications and suppliesValue (You pay After the calendar year deductible… )

We cover the following medications and supplies prescribed by your licensed attending physician or dentist and obtained from a Plan pharmacy or through our mail order program or an out-of-network retail pharmacy:

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

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

In-network: Deductible does not apply.

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

$10 per covered generic formulary drug;

30% per covered brand name formulary drug up to a $600 maximum; and

50% per covered non-formulary (generic or brand name) drug up to a $600 maximum.

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

$20 per covered generic formulary drug

30% per covered brand name formulary drug up to a $1,200 maximum; and

50% per covered non-formulary (generic or brand name) drug up to a $1,200 maximum.

Out-of-network (retail pharmacies only): The full cost of the prescription is applied to the deductible before any benefits are considered for payment under the pharmacy plan. Once the deductible is satisfied, the following will apply:

50% plus the difference between our Plan allowance and the billed amount.

Women's contraceptive drugs and devices

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

In-network: Nothing

Out-of-network (retail pharmacies only):
50% plus the difference between our Plan allowance and the billed amount.
  • Brand name contraceptive drugs
  • Brand name injectable contraceptive drugs such as Depo Provera - five (5) vials per calendar year
  • Brand emergency contraception

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

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

30% per covered brand name formulary drug up to a $600 maximum; and

50% per covered non-formulary (generic or brand name) drug up to a $600 maximum.

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

30% per covered brand name formulary drug up to a $1,200 maximum; and

50% per covered non-formulary (generic or brand name) drug up to a $1,200 maximum.

Out-of-network (retail pharmacies only):

50% plus the difference between our Plan allowance and the billed amount.

Specialty Medications

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

Certain Specialty Formulary medications identified on the Specialty Drug List may be covered under the medical or pharmacy section of this brochure. Please refer to page 131, Specialty Drugs for more information or visit:  www.aetnafeds.com/pharmacy.

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

Preferred: 50% up to a $600 maximum

Non-preferred: 50% up to $1,200 maximum

Limited benefits:

  • Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period. Note: Mail order is not available.

In-network:

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

$10 per covered generic formulary drug;

30% up to $600 per covered brand name formulary drug; and

50% up to $600 per covered non-formulary (generic or brand name) drug.

Out-of-network (retail pharmacies only):

50% plus the difference between our Plan allowance and the billed amount.

Benefit Description : Preventive care medicationsValue (You pay After the calendar year deductible… )

Medications to promote better health as recommended by ACA.

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

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

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

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

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

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

In-network:  Nothing

Not covered:

    • Drugs used for the purpose of weight reduction, such as appetite suppressants
    • Drugs for cosmetic purposes, such as Rogaine
    • Drugs to enhance athletic performance
    • Medical supplies such as dressings and antiseptics
    • Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law or covered by the plan
    • Lost, stolen or damaged drugs
    • Vitamins (including prescription vitamins), nutritional supplements not listed as a covered benefit, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition unless otherwise stated
    • Prophylactic drugs including, but no limited to, anti-malarials for travel
    • Fertility drugs
    • Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
    • Compounded thyroid hormone therapy

Note:  Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program.  (See page 109).  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.

All charges



Section 5(g). Dental Benefits (Value Plan)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 coordinating benefits with other coverage.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. We do not cover the dental procedure. See Section 5(c) for inpatient hospital benefits.



Dental benefits : Accidental injury benefitValue (You Pay After the calendar year deductible...)

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

We have no other dental benefits.

In-network: 20% of our Plan allowance

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




Section 5(h). Wellness and Other Special Features

TermDefinition
Flexible benefits option

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

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

Aetna Member website

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

You can:

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

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

Informed Health® Line

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




TermDefinition
Services for the deaf and hearing-impaired800-628-3323
National Medical Excellence ProgramNational 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 888-238-6240 for more information.



Non-FEHB Benefits Available to Plan Members

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

Vision Discounts

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

Hearing Discounts

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

Healthy lifestyle discounts

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

Natural products and services discount 

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

* The ChooseHealthy® program is provided by ChooseHealthy, Inc., a subsidiary of American Specialty Health Incorporated (ASH). ChooseHealthy is a federally registered trademark of ASH and used with permission here in.

**Discounts do not apply to visits/claims submitted to your health insurance plan.

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

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

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




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

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

We do not cover the following:

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



Section 7. Filing a Claim for Covered Services

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

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

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




TermDefinition

Medical, hospital and prescription drug benefits

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

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

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

  • Name of patient and relationship to enrollee
  • Covered member's name, date of birth, address, phone number and ID number
  • Name, address and taxpayer identification number of 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

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

In addition:

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

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

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

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

Overseas claims

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

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

Post-service claims procedures

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

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

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

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

Notice Requirements

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

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




Section 8. The Disputed Claims Process

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

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

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.  To make your request, please contact our Customer Service Department by writing Aetna, Attention:  National Accounts, P.O. Box 14463, Lexington, KY 40512 or calling 888-238-6240.

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

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

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

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

Disagreements between you and the CDHP fiduciary regarding the administration of an HRA are not subject to the disputed claims process.




StepDescription
1

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

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

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

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

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

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

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

 

 

2

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

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

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

3

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

4

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

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

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

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




Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 888-238-6240.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM's FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.

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




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage

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

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

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

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

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

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

  • TRICARE and CHAMPVA

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

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

  • Workers' Compensation

We do not cover services that:

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

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

  • Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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

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

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

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

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

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

This Plan always pays secondary to:

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

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

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

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

Note:  If the Plan recovers money through subrogation, the Medical Fund will not be reimbursed.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

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. If you are enrolled in our CDHP option and a FEDVIP Dental Plan, the FEDVIP plan will pay first for dental services and your Dental Fund will pay second, except for diagnostic and preventive care.  When you use an in network provider, diagnostic and preventive care will be reimbursed at 100% and not count against your Dental Fund, see page 48.  When you use a non-network dentist for these services, the Dental Fund will pay first and your FEDVIP plan will pay second.  When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

Recovery rights related to Workers' Compensation

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

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

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

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

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

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

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

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

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

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

Clinical trials

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

  • 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 pages 69 and 115.
  • 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 pages 72 and 118.
  • 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 pages 72 and 118.

When you have Medicare

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

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

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

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

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

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

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

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

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

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

CDHP: In-network example

Benefit Description: Deductible
CDHP Option You pay without Medicare: $1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment $2,000 for Self and Family enrollment in-network
CDHP Option You pay with Medicare Parts A and B (primary):$1,000 for Self Only enrollment, $2,000 for Self Plus One enrollment $2,000 for Self and Family enrollment in-network

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

Benefit Description: Primary Care Physician
CDHP Option You pay without Medicare: 15% of Plan allowance
CDHP Option You pay with Medicare Parts A and B (primary):15% of Plan allowance

Benefit Description: Specialist
CDHP Option You pay without Medicare: 15% of Plan allowance
CDHP Option You pay with Medicare Parts A and B (primary): 15% of Plan allowance

Benefit Description: In-Patient Hospital
CDHP Option You pay without Medicare: 15% of Plan allowance
CDHP Option You pay with Medicare Parts A and B (primary): 15% of Plan allowance

Benefit Description: Out-Patient Hospital
CDHP Option You pay without Medicare:15% of Plan allowance
CDHP Option You pay with Medicare Parts A and B (primary): 15% of Plan allowance

Benefit Description: Incentives Offered
CDHP Option You pay without Medicare: N/A
CDHP Option You pay with Medicare Parts 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 888-238-6240 or visit our website at www.aetnafeds.com.

  • Tell us about your Medicare coverage

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

  • Medicare Advantage (Part C)

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

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

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

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

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

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

  • Medicare prescription drug coverage (Part D)

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




Primary Payer Chart

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


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


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

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




Section 10. Definitions of Terms We Use in This Brochure

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

Catastrophic Protection

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

CDHP

Self Only:

In-network: Your annual out-of-pocket maximum is $5,000.

Out-of-network: Your annual out-of-pocket maximum is $6,000.

Self Plus One:

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

Out-of-network: Your annual out-of-pocket maximum is $12,000.

Self and Family:

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

Out-of-network: Your annual out-of-pocket maximum is $12,000.

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. In-network and Out-of-network out-of-pocket maximums do not cross apply and will need to be met separately in order for eligible medical expenses to be paid at 100%.

Value Plan

Self Only:

In-network:  Your annual out-of-pocket maximum is $6,000.

Out-of-network: Your annual out-of-pocket maximum is $7,000.

Self Plus One:

In-network: Your annual out-of-pocket maximum is $12,000.

Out-of-network: Your annual out-of-pocket maximum is $14,000.

Self and Family:

In-network:  Your annual out-of-pocket maximum is $12,000.

Out-of-network: Your annual out-of-pocket maximum is $14,000.

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

Clinical Trials Cost Categories

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; 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 pages 69 and 115.
  • 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 pages 72 and 118.
  • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials.  This Plan does not cover these costs.  See pages 72 and 118.

Coinsurance

See Section 4, page 33.

Copayment

See Section 4, page 32.

Cost-sharing

See Section 4, page 32.

Covered services

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

Custodial care

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

Deductible

See Section 4, page 32.

Detoxification

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

Emergency care An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a pregnant woman, the health of the woman and her unborn child.

Experimental or investigational services

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

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

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

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

Medical necessity

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

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

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

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

Plan allowance

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

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

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

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

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

Plan allowance/Recognized charge: 105% of the Medicare allowable rate

Service or Supply: Services of Hospitals and other facilities

Plan allowance/Recognized charge: 140% of the Medicare allowable rate

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

Geographic area is normally based on the first three digits of the U.S. Postal Service zip codes. If we determine we need more data for a particular service or supply, we may base rates on a wider geographic area such as an entire state.Special terms used

  • Involuntary services are services or supplies that are one of the following:
    • Performed at a network facility by an out-of-network provider, unless that out-of-network provider is an assistant surgeon for your surgery
    • Not available from a network provider
    • Emergency services

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

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

Our reimbursement policies

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

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

Our reimbursement policies are based on our review of:

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

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

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

Note:  See page 33 of this brochure and www.aetnafeds.com for examples of member cost sharing for procedures in and out-of-network.

Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims were treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
Precertification

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

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

Note: Since this Plan pays out-of-network benefits and you may self-refer for covered services, it is your responsibility to contact Aetna to precertify those services which require precertification. You must obtain precertification for certain types of care rendered by non- network providers to avoid a reduction in benefits paid for that care.
Preventive care Health care services designed for prevention and early detection of illnesses in average risk people, generally including routine physical examinations, tests and immunizations.
ReimbursementA carrier's pursuit of a recovery is a covered individual that has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Respite care

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

RolloverAny unused, remaining balance in your CDHP Medical Fund or Dental Fund at the end of the calendar year may be rolled over to subsequent years.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a worker's compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

Urgent care

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

Urgent care claims

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

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

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

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

Us/We

Us and we refer to Aetna Life Insurance Company.

You

You refers to the enrollee and each covered family member.




Consumer Driven Health Plan (CDHP) Definitions

TermDefinition

Calendar year deductible

Your calendar year deductible is $1,000 for Self only enrollment, $2,000 for Self Plus One enrollment or $2,000 for Self and Family enrollment in-network and $1,500 for Self Only enrollment, $3,000 for Self Plus One enrollment and $3,000 for Self and Family enrollment out-of-network. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

Consumer Driven Health Plan

A network provider plan under the FEHB that offers you greater control over choices of your health care expenditures.

Dental Fund (Consumer Driven Health Plan)

Your Dental Fund is an established benefit amount which is available for you to use to pay for covered dental expenses. You determine how your Dental Fund will be spent and any unused amount at the end of the year will be rolled over in subsequent year(s).

Medical Fund (Consumer Driven Health Plan)

Your Medical Fund is an established benefit amount which is available for you to use to pay for covered hospital, medical and pharmacy expenses. All of your claims will initially be deducted from your Medical Fund.  Once you have exhausted your Medical Fund, and have satisfied your deductible, Traditional medical coverage begins.

The Medical Fund is not a cash account and has no cash value.  It does not duplicate other coverage provided by this brochure.  It will be terminated if you are no longer covered by this Plan.  Only eligible expenses incurred while covered under the Plan will be eligible for reimbursement subject to timely filing requirements.  Unused Medical Funds are forfeited.




Index

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



Index Entry
(Page numbers solely appear in the printed brochure)
Accidental injury
Allergy tests
Allogeneic transplants
Alternative treatments
Ambulance
Anesthesia
Autologous transplants
Bariatric Surgery
Biopsy
Blood plasma
Casts
Catastrophic protection out-of-pocket maximum
Changes for 2021
Chemotherapy
Chiropractic
Cholesterol
Claims
Coinsurance
Colorectal cancer screening
Congenital anomalies
Consumer Driven Health Plan
Contraceptives
Cost-sharing
Covered charges
Crutches
Deductible
Definitions
Dental care
Dental Fund
Diagnostic services
Disputed claims
Donor
Dressings
Durable medical equipment
Educational classes and programs
Effective date of enrollment
Emergency
Experimental or investigational
Eyeglasses
Family planning
Fecal occult blood test
Fraud
General exclusions
Hearing services
Home health services
Hospice care
Hospital
Immunizations
Infertility
Insulin
Magnetic Resource Imaging (MRI)
Mammogram
Maternity Benefits
Medicaid
Medical Fund
Medically necessary
Medicare
Original
Mental Health/Substance Misuse Disorder Benefits
Network providers
Newborn
Non-FEHB benefits
Non-network providers
Nurse
Occupational therapy
Oral and maxillofacial surgery
Orthopedic devices
Out-of-pocket expenses
Outpatient
Oxygen
Pap test
Physical therapy
Physician
Plan allowance
Precertification
Prescription drugs
Preventive care
Prosthetic devices
Radiation therapy
Reconstructive
Rollover
Room and board
Skilled nursing facility
Smoking cessation
Speech therapy
Splints
Subrogation
Surgery
Anesthesia
Oral
Outpatient
Reconstructive
Temporary Continuation of Coverage (TCC)
Transplants
Treatment therapies
Trial
Urgent Care
Vision services
Wheelchairs
Workers’ Compensation
X-rays



Notes

Index Entry
(Page numbers solely appear in the printed brochure)
Accidental injury
Allergy tests
Allogeneic transplants
Alternative treatments
Ambulance
Anesthesia
Autologous transplants
Bariatric Surgery
Biopsy
Blood plasma
Casts
Catastrophic protection out-of-pocket maximum
Changes for 2021
Chemotherapy
Chiropractic
Cholesterol
Claims
Coinsurance
Colorectal cancer screening
Congenital anomalies
Consumer Driven Health Plan
Contraceptives
Cost-sharing
Covered charges
Crutches
Deductible
Definitions
Dental care
Dental Fund
Diagnostic services
Disputed claims
Donor
Dressings
Durable medical equipment
Educational classes and programs
Effective date of enrollment
Emergency
Experimental or investigational
Eyeglasses
Family planning
Fecal occult blood test
Fraud
General exclusions
Hearing services
Home health services
Hospice care
Hospital
Immunizations
Infertility
Insulin
Magnetic Resource Imaging (MRI)
Mammogram
Maternity Benefits
Medicaid
Medical Fund
Medically necessary
Medicare
Original
Mental Health/Substance Misuse Disorder Benefits
Network providers
Newborn
Non-FEHB benefits
Non-network providers
Nurse
Occupational therapy
Oral and maxillofacial surgery
Orthopedic devices
Out-of-pocket expenses
Outpatient
Oxygen
Pap test
Physical therapy
Physician
Plan allowance
Precertification
Prescription drugs
Preventive care
Prosthetic devices
Radiation therapy
Reconstructive
Rollover
Room and board
Skilled nursing facility
Smoking cessation
Speech therapy
Splints
Subrogation
Surgery
Anesthesia
Oral
Outpatient
Reconstructive
Temporary Continuation of Coverage (TCC)
Transplants
Treatment therapies
Trial
Urgent Care
Vision services
Wheelchairs
Workers’ Compensation
X-rays



Summary of Benefits for the Aetna HealthFund CDHP Plan - 2021

  • Do not rely on this chart alone.  This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.aetnafeds.com.  
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • For the Consumer Driven Health Plan (CDHP), your health charges are applied to your Medical Fund ($1,000 for Self Only, $2,000 for Self Plus One, and $2,000 for Self and Family) plus rollover amounts.  Once your Medical Fund has been exhausted, you must satisfy your calendar year deductible, $1,000 for Self Only, $2,000 for Self Plus One, and $2,000 for Self and Family in-network and $1,500 for Self Only, $3,000 for Self Plus One and $3,000 for Self and Family enrollment out-of-network.  You pay any difference between our allowance and the billed amount if you use a non-network physician or other health care professional. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits.



TermDefinition 1Definition 2

In-network medical and dental preventive care

Nothing at a network provider

42

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

53

In-network Teladoc provider consult

 
Note: Teladoc is not available for phone service in Idaho (video consult only). 

$40 per consultation

53

Services provided by a hospital:

  • Inpatient

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

75

Services provided by a hospital:

  • Outpatient

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

75

Emergency benefits:

In-network:  15% of our Plan allowance

Out-of-network:  15% of our Plan allowance and any difference between our allowance and the billed amount.

79

Mental health and substance use disorder treatment:

 

In-network: 15% of our Plan allowance

Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.

81

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

Preferred: 50% per covered specialty drug up to a $350 maximum

Non-preferred: 50% per covered specialty drug up to $700 maximum

87

Dental care: Dental Fund of $300 for Self Only or $600 for Self Plus One or Self and Family

In-network: After your Dental Fund has been exhausted, the negotiated rates offered by participating network PPO dentists.

Out-of-network: After your Dental Fund has been exhausted, all charges.

48

Vision care: In-network (only) preventive care benefits.

Nothing

43

Vision care:  Corrective eyeglasses and frames or contact lenses (hard or soft).

Nothing up to your available Medical Fund balance. All charges if Medical Fund balance is exhausted.

59

Special features: Flexible benefits optionInformed Health Line, and Services for the deaf and hearing-impaired

Contact Plan

137

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

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

Out-of-network: Nothing after $6,000/Self Only enrollment, $12,000/Self Plus One enrollment, or $12,000/Self and Family enrollment per year.

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

34




Summary of Benefits for the Value Plan - 2021

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



TermDefinition 1Definition 2

In-network medical preventive care

Nothing

94

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

In-network: $25 per primary care physician (PCP) visit, $40 per specialist visit (no deductible)

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

 

99

In-network Teladoc provider consult
Note: Teladoc is not available for phone service in Idaho (video consult only). 

 

$40 per consultation (no deductible)

99

Services provided by a hospital:

  • Inpatient

In-network: 20% of our Plan allowance

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

 

121

Services provided by a hospital:

  • Outpatient

In-network: 20% of our Plan allowance

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

 

121

Emergency benefits:

In-network: 20% of our Plan allowance

Out-of-network:  20% of our Plan allowance and any difference between our allowance and the billed amount.

 

125

Mental health and substance use disorder treatment:

In-network: 20% of our Plan allowance

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

127

Prescription Drugs:

.

129

Retail Pharmacy

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

$10 per covered generic formulary drug; 30% per covered brand name formulary drug up to a $600 maximum; 50% per covered non-formulary (generic or brand name) drug up to a $600 maximum.

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

132

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

Preferred: 50% per covered specialty drug up to a $600 maximum

Non-preferred: 50% per covered specialty drug up to $1,200 maximum

133

  • Mail order (available in-network only)

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

$20 per covered generic formulary drug

30% per covered brand name formulary drug up to a $1,200 maximum; and

50% per covered non-formulary (generic or brand name) drug up to a $1,200 maximum.

132

Dental care:

No benefit

136

Vision care:  In-network (only) preventive care benefits.

Nothing

95

Special features: Flexible benefits option, Informed Health Line, and Services for the deaf and hearing-impaired

Contact Plan

137

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

In-network:  Nothing after $6,000/Self Only enrollment, $12,000/Self Plus One enrollment, or $12,000/Self and Family enrollment per year.

Out-of-network: Nothing after $7,000/Self Only enrollment, $14,000/Self Plus One enrollment, or $14,000/Self and Family enrollment per year.

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

34




2021 Rate Information for the Aetna HealthFund CDHP / Aetna Value Plan

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

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

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

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

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

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

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

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

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




AL, AR, DC, FL, GA, LA, MD, NC, TN, VA, WV
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
CDHP Option Self OnlyF51$241.58$151.53$523.42$328.32$148.17$138.11
CDHP Option Self Plus OneF53$517.46$369.99$1,121.16$801.65$362.80$341.24
CDHP Option Self and FamilyF52$562.25$334.07$1,218.21$723.82$326.26$302.84
Value Option Self OnlyF54$241.58$137.72$523.42$298.40$134.36$124.30
Value Option Self Plus OneF56$517.46$334.06$1,121.16$723.80$326.87$305.31
Value Option Self and FamilyF55$562.25$306.31$1,218.21$663.67$298.50$275.08
CT, DE, MA, ME NH, NJ, NY, RI, VT
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
CDHP Option Self OnlyEP1$241.58$277.49$523.42$601.23$274.13$264.07
CDHP Option Self Plus OneEP3$517.46$654.60$1,121.16$1,418.30$647.41$625.85
CDHP Option Self and FamilyEP2$562.25$621.54$1,218.21$1,346.67$613.73$590.31
Value Option Self OnlyEP4$241.58$145.94$523.42$316.21$142.58$132.52
Value Option Self Plus OneEP6$517.46$352.52$1,121.16$763.80$345.33$323.77
Value Option Self and FamilyEP5$562.25$325.14$1,218.21$704.47$317.33$293.91
ID, IL, IA, KY, MN, MS, MT, ND, NE, OR, PA, WY
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
CDHP Option Self OnlyH41$241.58$140.04$523.42$303.42$136.68$126.62
CDHP Option Self Plus OneH43$517.46$343.97$1,121.16$745.27$336.78$315.22
CDHP Option Self and FamilyH42$562.25$307.63$1,218.21$666.53$299.82$276.40
Value Option Self OnlyH44$241.58$135.72$523.42$294.06$132.36$122.30
Value Option Self Plus OneH46$517.46$331.49$1,121.16$718.23$324.30$302.74
Value Option Self and FamilyH45$562.25$303.67$1,218.21$657.95$295.86$272.44
AZ, CO, KS, MI, MO, NV, NM, SD, UT, WA
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
CDHP Option Self OnlyG51$241.58$247.08$523.42$535.34$243.72$233.66
CDHP Option Self Plus OneG53$517.46$586.17$1,121.16$1,270.04$578.98$557.42
CDHP Option Self and FamilyG52$562.25$552.40$1,218.21$1,196.87$544.59$521.17
Value Option Self OnlyG54$241.58$89.36$523.42$193.62$86.00$75.94
Value Option Self Plus OneG56$517.46$225.66$1,121.16$488.93$218.47$196.91
Value Option Self and FamilyG55$562.25$195.72$1,218.21$424.06$187.91$164.49
AK, CA, HI, IN, OH, OK, SC, TX, WI
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
CDHP Option Self OnlyJS1$241.58$224.54$523.42$486.51$221.18$211.12
CDHP Option Self Plus OneJS3$517.46$534.54$1,121.16$1,158.17$527.35$505.79
CDHP Option Self and FamilyJS2$562.25$500.28$1,218.21$1,083.94$492.47$469.05
Value Option Self OnlyJS4$241.58$263.61$523.42$571.16$260.25$250.19
Value Option Self Plus OneJS6$517.46$624.42$1,121.16$1,352.91$617.23$595.67
Value Option Self and FamilyJS5$562.25$591.04$1,218.21$1,280.59$583.23$559.81