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

Aetna Health of Utah Inc. dba Altius Health Plan

www.aetnafeds.com/altius
800-537-9384

2021



IMPORTANT:
  • Rates
  • Changes for 2021
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization (High and Standard) Options and a High Deductible Health Plan (HDHP) Option.

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.


Serving: Utah, Idaho and Wyoming

Enrollment in this plan is limited. You must live or work in our geographic service area to enroll. See page 20 for requirements.

Enrollment codes for this Plan:

9K1 High Option - Self Only
9K3 High Option - Self Plus One 
9K2 High Option - Self and Family


DK4 Standard Option - Self Only
DK6 Standard Option - Self Plus One 
DK5 Standard Option - Self and Family


9K4 HDHP Option - Self Only
9K6 HDHP Option - Self Plus One 
9K5 HDHP Option - Self and Family
FEHB LogoOPM Logo








Important Notice

Important Notice from Altius Health Plans About Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the Altius Health Plans’ 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 High, Standard and High Deductible Health Plan options for Aetna Health of Utah Inc. dba Altius Health Plan under Aetna contract (CS 2839) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at 800-537-9384 or through our website: www.aetnafeds.com/altius. The address for the Plan's administrative offices is:

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

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

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

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2021, and changes are summarized on page 21. Rates are shown at the end of this brochure.




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 Altius Health Plans.
  • 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 to 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 800-537-9384 and explain the situation.
    • If we do not resolve the issue:

CALL- THE HEALTH CARE FRAUD HOTLINE
877-499-7295
OR go to:

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

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

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

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

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

  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining services 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 your medication if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions.
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

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

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

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital 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 us Altius Health Plans 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 do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, 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 in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below.

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

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

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

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

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have 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 than 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 job, if you are a covered dependent child and you turn age 26, regardless of marital status, 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 premiums, 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 coverage.

  • Finding replacement coverage

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

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

  • Health Insurance Marketplace

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




Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory. You have a choice of enrollment in a High Option, a Standard Option, or a High Deductible Health Plan (HDHP) Option.

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:

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

General features of our High and Standard Options

  • The deductible for our High and Standard Option plans is:
    • High Option: $50 for Self Only or $100 for Self Plus One or Self and Family coverage
    • Standard Option: $100 for Self Only or $200 for Self Plus One or Self and Family coverage.

Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits.  The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

  • Most services provided by physicians and other health care professionals, including physician services that are provided while you are in a hospital, may be subject to a copayment or coinsurance.
  • Comprehensive dental coverage is included in our High Option.
  • The Standard Option does not include dental coverage (except for dental services that are necessary as a result of an accidental injury to sound, natural teeth).

We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and copayments, cannot exceed:

  • High Option: $5,500 for Self Only or $11,000 for Self Plus One or Self and Family coverage.
  • Standard Option: $6,000 for Self Only or $12,000 for Self Plus One or Self and Family coverage.

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.

We have Open Access benefits

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

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). We compensate contracted providers by either discount fee-for-service fee schedules or capitation agreements. It is your responsibility to verify that the provider you use is a Plan provider. Except for emergency and out-of-area urgent care, we will not pay for care or services from non-Plan providers or facilities unless it has been authorized by us. If you use a non-Plan provider or facility without authorization from us, you may be responsible for all charges.

You do not have to select a Primary Care Physician (PCP), you may self-refer to Plan specialists. However, we recommend that you select a PCP to coordinate all of your medical care. A PCP should practice one of the following disciplines: General Practice, Family Medicine, Internal Medicine, Obstetrics/Gynecology (OB/GYN), or Pediatrics. You are responsible for making sure that a provider is a Plan provider. Should you have any questions, please contact our Customer Service Department at 800-537-9384, or visit our website at www.aetnafeds.com.

General features of our High Deductible Health Plan (HDHP)

An HDHP is a health plan product that provides traditional health care coverage and a tax-advantaged way to help you build savings for future medical needs. An HDHP with an HSA or HRA is designed to give greater flexibility and discretion over how you use your health care benefits. As an informed consumer, you decide how to utilize your plan coverage with a high deductible and out-of-pocket expenses limited by catastrophic protection. And you decide how to spend the dollars in your HSA or HRA. You have:

  • An HSA in which the Plan will automatically deposit $62.50 per month/Self Only or $125.00 per month/Self Plus One or $125.00 per month/Self and Family.
  • The ability to make voluntary contributions to your HSA of up to $2,850/Self Only or $5,700/Self Plus One or $5,700/Self and Family per year. If you are age 55 or older, you may also make a catch-up contribution of up to $1,000 for 2021.

You may consider:

  • Using the most cost effective provider.
  • Actively pursuing a healthier lifestyle and utilizing your preventive care benefit.
  • Becoming an informed health care consumer so you can be more involved in the treatment of any medical condition or chronic illness.

 The type and extent of covered services, and the amount we allow, may be different from other plans. Read our brochure carefully to understand the benefits and features of this HDHP. The IRS website at https://www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx has additional information about HDHPs.

Preventive care services

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.

Annual deductible

The annual deductible of $1,400 for Self Only, $2,800 for Self Plus One or $2,800 for Self and Family must be met before Plan benefits are paid for care other than preventive care services. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

Health Savings Account (HSA)

You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP (including a spouse's health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not received VA (except for veterans with a service-connected disability), or Indian Health Service (IHS) benefits within the last three months, and are not claimed as a dependent on someone else's tax return.

  • You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense.
  • Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by a HDHP.
  • You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
  • For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. In addition, your HSA dollars earn tax-free interest.
  • You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable - you may take the HSA with you if you leave the Federal government or switch to another plan.

Health Reimbursement Arrangement (HRA)

If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.

  • An HRA does not earn interest.
  • An HRA is not portable if you leave the Federal government or switch to another plan.

You must notify us that you are ineligible for an HSA. If we determine that you are ineligible for an HSA, we will notify you by letter and provide an HRA for you.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and copayments, and coinsurance cannot exceed $6,000 for Self only enrollment, and $12,000 for a Self Plus One or 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. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.

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 HDHP Section 5(i).

Your member website gives you direct access to:

  • Personal Health Record that provides you with online access to your personal health information including health care providers, drug prescriptions, medical tests, individual personalized messages, alerts and a detailed health history that can be shared with your physicians.
  • Care and Costs tools that compare 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 Altius 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.
  • Healthwise® Knowledgebase where you get information on thousands of health-related topics to help you make better decisions about your health care and treatment

For more information about these and other available tools and resources, please see HDHP Section 5(i).

Your rights and responsibilities

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

  • Altius Health Plan is a licensed Health Maintenance Organization in Utah, Idaho and Wyoming.
  • Altius Health Plan has been in existence for more than 30 years.
  • Altius Health Plan is a for-profit, Aetna Company.

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

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

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our Aetna 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 prescriptions drug utilization) to any of our 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 Altius.

Direct Access Ob/Gyn Program

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

Mental Health/Substance Use

Behavioral health services (e.g. treatment or care for mental disease or illness, alcohol abuse and/or substance use) are managed by Aetna Behavioral Health. We also make initial coverage determinations and coordinate referrals, if required; any behavioral health care referrals will generally be made to providers affiliated with the organization, unless your needs for covered services extend beyond the capability of these providers. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the terms of your health plan.

Ongoing Reviews

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

Authorization

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

Patient Management

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

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

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 Altius 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 Altius to ensure coverage for those services. When you are to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment.

Concurrent Review

The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review.

Discharge Planning

Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by you upon discharge from an inpatient stay.

Retrospective Record Review

The purpose of retrospective record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions for coverage and payment of health care services. Our effort to manage the services provided to you includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and utilization concerns.

Member Services

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

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

Privacy Notice

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

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

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

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

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

Service Area

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

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

Portions of Emery and Grand as defined by the following zip codes:

Emery - 84513, 84516, 84518, 84521, 84522, 84523, 84528, 84537

Grand - 84515, 84532

Idaho - The counties of Ada, Adams, Bannock, Bear Lake, Bingham, Blaine, Boise, Bonneville, Camas, Canyon, Caribou, Cassia, Clark, Custer, Elmore, Franklin, Fremont, Gem, Gooding, Jefferson, Jerome, Lincoln, Madison, Minidoka, Oneida, Owyhee, Payette, Power, Teton, Twin Falls, Valley and Washington.

Wyoming - The counties of Lincoln, Sweetwater, and Uinta

You must receive your care from providers who contract with us. If you receive care outside our service area, we will pay only for urgent or emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), they will be able to access full HMO benefits if they reside in any Aetna HMO service area by selecting a PCP in that service area. If not, you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.




Section 2. Changes for 2021

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

Changes to High Option only

  • Your share of the non-Postal premium will increase for Self Only, and increase for Self Plus One, and increase for Self and Family. (See page 162)
  • Outpatient hospital - The Plan is decreasing the copay from $450 per visit after deductible to $400 per visit after deductible. (See page 58) 

Changes to the Standard Option only

  • Your share of the non-Postal premium will increase for Self Only, and increase for Self Plus One, and increase for Self and Family. (See page 162)

Changes to the High Deductible Health Plan only

  • Your share of the non-Postal premium will increase for Self Only, and increase for Self Plus One, and increase for Self and Family. (See page 162)
  • Investment fee for the Health Savings Account (HSA) - PayFlex will begin charging members .02% per month of the investment account balance. It will be charged by PayFlex only when a member voluntarily chooses to invest the funds from their HSA account into the investment account. (See page 87)

Changes to the High Option, Standard Option and High Deductible Health Plan (HDHP) Option

  • 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 pages 24-25)

  • Specialty drugs - The Plan will now require members to fill all specialty drugs at an Aetna Performance Specialty Network pharmacy. (See pages 67 and 126)

  • 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 69 and 128)

  • 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 69 and 128)



Section 3. How You Get Care

TermDefinition

Open Access HMO

This Open Access Plan is available to our members in those FEHB Program service areas identified starting on page 20. You can go directly to any network specialist for covered services without a referral from your primary care physician. Whether your covered services are provided by your selected primary care physician (for your PCP copay) or by any other participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.

Identification cards

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

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

Where you get covered careYou must receive care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance based on your benefit plan selection.  This plan is Open Access which means you may receive covered services from any participating provider without a required referral from your primary care physician. Some services may require prior approval from the Plan.

Plan providers

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

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

Plan facilities

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

What you must do to get covered careIt depends on the type of care you need.  You and each family member are encouraged to choose a primary care physician.  This decision is important since your primary care physician provides or arranges for most of your health care.  You must select a Plan provider who is located in your service area as defined by your enrollment code.
Primary care

Your primary care physician can be a General Practitioner, Family Practitioner, Internist, or Pediatrician.  Your primary care physician will provide most of your health care.

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

Specialty care

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

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

  • If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
  • If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
  • If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Program plan; or
  • reduce our service area and you enroll in another FEHB plan;

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

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

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

If you are hospitalized when your enrollment begins

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

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

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

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

You need prior Plan approval for certain services

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

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

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

Other services

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

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

*For a complete list refer to: 

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

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

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

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

Next, provide the following information:

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

Non-urgent care claims

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

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 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 within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

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

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

Concurrent care claims

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

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

Emergency inpatient admission

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within one (1) business 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 or less for a vaginal delivery or a total of five (5) days or less for a cesarean, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.

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

If your treatment needs to be extended

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

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.  In that case, we will make all reasonable efforts to provide you with the necessary care.

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 six (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 Costs for Covered Services

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



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

Copayments

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

Example: When you see a primary care physician, you pay a copayment of $25 per office visit; and when you see a specialist, you pay a copayment of $40 per office visit.

High Deductible Health Plan Example: When you see a primary care physician, you pay a copayment of $20 per office visit (after your deductible has been met). When you see a specialist, you pay a copayment of $30 per office visit (after your deductible has been met).

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments and coinsurance amounts do not count toward any deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible.

  • High Option: The calendar year deductible is $50 for Self Only enrollment. The calendar year deductible is $100 Under a Self Plus One and Self and Family enrollment. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
  • Standard Option: The calendar year deductible is $100 for Self Only enrollment. The calendar year deductible is $200 under a Self Plus One and Self and Family enrollment. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
  • High Deductible Health Plan: The calendar year deductible is $1,400 for individual coverage (Self Only enrollment). The calendar year deductible is $2,800 under a Self Plus One and Self and Family enrollment. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.

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 50% of our allowance for infertility services and durable medical equipment. (With the High Deductible Health Plan, this coinsurance applies after your deductible has been met.)

Differences between our Plan allowance and the bill

 

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows: The total dollar amount allowed by the Plan for Covered Services, including the amounts payable by the Plan and payable by you.

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.

Your catastrophic protection out-of-pocket maximum

High Option

After your deductible, copayments and/or coinsurance total $5,500 for Self Only or $11,000 per Self Plus One, or $11,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services for the remainder of the calendar year. Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical expenses at 100%. The remaining balance of the Self Plus One or Self and Family out-of-pocket maximum can be satisfied by one or more family members. However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

  • Dental services

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

Standard Option

After your deductible, copayments and/or coinsurance total $6,000 for Self Only or $12,000 per Self Plus One or $12,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services for the remainder of the calendar year. 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 and coinsurance to ensure the Plan's calculation of your out-of-pocket maximum is reflected accurately.

High Deductible Health Plan

After your deductibles, copayments, and/or coinsurance total $6,000 for Self Only or $12,000 per Self Plus One or $12,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services for the remainder of the calendar year. 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.  If you have a question about when the out-of-pocket maximum is reached, please call our Customer Service Department at 800-537-9384.

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 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. High and Standard Option Benefits (High and Standard Options)

See page 21 for how our benefits changed this year and pages 158-159 for a benefits summary.

This plan offers both a High and Standard Option.  Both benefit packages are described in Section 5.  Make sure that you review the benefits that are available under the option in which you are enrolled.

Note: This benefits section 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 our benefits, contact us at 800-537-9384 or at our website at www.aetnafeds.com.




(Page numbers solely appear in the printed brochure)

Table of Content



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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care. You are responsible for ensuring that your provider is a Plan provider.
  • The deductible is $50 Self Only or $100 for Self Plus One or Self and Family enrollment for High Option and $100 Self Only or $200 for Self Plus One or Self and Family enrollment for Standard Option each calendar year. The deductible applies to all benefits in this section. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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. (except where noted otherwise).
  • A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • We encourage you to select a PCP by calling Member Services at 800-537-9384.
  • YOUR PHYSICIAN MUST OBTAIN PRIOR AUTHORIZATION FOR CERTAIN SERVICES, SUPPLIES, AND DRUGS. Please refer to Section 3 for prior authorization information and to be sure which services require prior authorization.



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

Professional services of physicians

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

$25 per office visit to a primary care physician

$40 per office visit to a specialist

$25 per office visit to a primary care physician

$45 per office visit to a specialist

  • In an urgent care center
$40 per visit$40 per visit
  • During a hospital stay
  • In a skilled nursing facility

Nothing

See section 5(c) for facility charges.

15% of Plan Allowance

See section 5(c) for facility charges.

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

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).

$30 per consult$40 per consult
Benefit Description : Lab, X-ray and other diagnostic testsHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)

Minor diagnostic tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap tests
  • Pathology
  • X-rays
  • Non-routine mammograms
  • Ultrasound
  • Electrocardiogram and EEG
  • Sleep studies
$30 copay$40 copay

Major diagnostic labs and radiology tests, such as:

  • CT scans, MRIs, MRAs, and electron beam scans
  • PET and SPECT scans
  • Angiography, and other procedures that require vascular catheterization and/or the injection of medication, imaging contrast, or other substance
  • Any radiological procedure that must be performed in conjunction with a diagnostic surgical procedure (for example: ultrasonic guidance procedures)
  • Diagnostic nuclear medicine, including provision of radiopharmaceuticals for diagnostic purposes
  • Cytogenetic studies

$200 copay

$250 copay

Benefit Description : Preventive care, adultHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)
  • 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/

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

Nothing (no deductible)

Nothing (no deductible)

Routine mammogram – covered for women as follows:

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

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

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

Nothing (no deductible)

Nothing (no deductible)

Not covered:

  • Physical exams and immunizations 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

All charges

Benefit Description : Preventive care, childrenHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

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

Well-child care charges for routine examinations, immunizations and care (up to age 26)

  • 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 26

Examinations such as:

  • Vision Screening through age 17 to determine the
    need for vision correction
  • Hearing exams through age 17 to determine
    the need for hearing correction
  • Routine examinations done on the day of immunizations (up to age 26)

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

Nothing (no deductible)

Nothing (no deductible)

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

All charges

Benefit Description : Maternity careHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)

Complete maternity (obstetrical) care, such as:

  • Routine Prenatal care includes the initial and subsequent history, physical examinations, recording of weight, blood pressure, 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 page 24 for other circumstances, such as extended stays for you or your baby.
  • You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will extend your inpatient stay if medically necessary but you, your representative, your participating doctor, or your hospital must precertify the extended stay.
  • We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury. Please refer to Section 5(c). Services provided by a hospital or other facility, and ambulance services for inpatient maternity benefit coverage.

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.

No copay (no deductible) for routine prenatal care or the first postpartum care visit

$25 for PCP or $40 for specialist visit for postpartum care visits thereafter

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

No copay (no deductible) for routine prenatal care or the first postpartum care visit

$25 for PCP or $45 for specialist visit for postpartum care visits thereafter

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

Breastfeeding support, supplies and counseling for each birth

Nothing (no deductible) 

Nothing (no deductible) 

Not covered:

  • Home delivery
All chargesAll charges
Benefit Description : Family planning High Option (You pay after deductible:)Standard Option (You pay after deductible:)

A range of voluntary family planning services, such as:

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

Nothing (no deductible) for women

For men:

$25 per PCP visit

$40 for Specialist visit

Nothing (no deductible) for women

For men:

$25 per PCP visit

$45 for Specialist visit

Not covered:

  • Reversal of voluntary surgical sterilization
  • Predictive Genetic testing and/or counseling
All charges All charges
Benefit Description : Infertility servicesHigh Option (You pay after deductible:)Standard Option (You pay after 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.
50% of Plan Allowance50% of Plan Allowance

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):
        – 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 voluntary, surgically-induced sterility 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
  • The purchase, freezing and storage of donor sperm and donor embryos.
  • 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 chargesAll charges
Benefit Description : Allergy careHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)
  • Testing and treatment

$25 per office visit to a primary care physician

$40 per office visit to a specialist

$25 per office visit to a primary care physician

$45 per office visit to a specialist

  • Allergy serum
  • Allergy injections
NothingNothing

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All charges All charges
Benefit Description : Treatment therapiesHigh Option (You pay after deductible:)Standard Option (You pay after 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 49.

  • Respiratory and inhalation therapy
  • Cardiac rehabilitation following qualifying event/condition is provided for up to 12 weeks for Phase II and Phase III combined
  • Dialysis – hemodialysis and peritoneal dialysis
  • Growth hormone therapy (GHT)
  • Intravenous (IV) Infusion Therapy in a doctor’s office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services.)

Note: When provided in a physician’s office or in an urgent care center, the services listed above do not include the cost of injectable, implantable and IV drugs; see below for the cost of the drugs.

Note: We cover home IV infusion and antibiotic therapy administered by a home health agency under the Home health services benefit.

Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Section 3 - Other services under You need prior Plan approval for certain services.

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

$25 per office visit to a primary care physician

$40 per office visit to a specialist

$400 per visit in a surgical center, hospital, or other facility

$25 per office visit to a primary care physician

$45 per office visit to a specialist

$650 per visit in a surgical center, hospital, or other facility

Benefit Description : Physical, speech, and occupational habilitative and rehabilitative therapiesHigh Option (You pay after deductible:)Standard Option (You pay after 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: We cover physical and occupational therapy under the Home health services benefit when provided by a home health agency as part of an authorized home treatment plan.

$40 per office visit

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

$45 per office visit

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

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

$25 per office visit

$25 per office visit

  • Outpatient cardiac rehabilitation following qualifying event/condition is provided at a Plan facility for up to 12 weeks for Phase II and Phase III combined.

$40 per office visit

$45 per office visit

Not covered:

  • Long-term habilitative and/or rehabilitative therapy
  • Therapy that we determine will not significantly improve your condition
  • Exercise programs
All chargesAll charges
Benefit Description : Speech therapyHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)
60 visits per person per calendar year

$40 per office visit

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

$45 per office visit

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

Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You pay after deductible:)Standard Option (You pay after deductible:)
  • For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

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

$25 per office visit to a primary care physician

$40 per office visit to a specialist

$25 per office visit to a primary care physician

$45 per office visit to a specialist

  • External hearing aids
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices.

For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices

For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices

Not covered: 

  • Hearing services that are not shown as covered
All chargesAll charges
Benefit Description : Vision services (testing, treatment, and supplies)High Option (You pay after deductible:)Standard Option (You pay after deductible:)
  • Corrective eyeglasses and frames or contact lenses (hard or soft) for adults age 19 and older per 24-month period.
All charges over $100

All charges over $100

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

*Note: You must pay out-of-pocket for charges above the $100 allowance and submit a claim form for reimbursement of the 10%.

90% of charges after $10090% of charges after $100
  • One (1) routine eye exam (including refraction) every 12 month period

Note: See Preventive care, children for eye exams for children

Nothing (no deductible)

Nothing (no deductible) 

  • Treatment of eye diseases and injury

$40 per Specialist office visit

$45 per Specialist office visit

Not covered:

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

$25 per office visit to a primary care physician 

$40 per office visit to a specialist

$25 per office visit to a primary care physician

$45 per office visit to a specialist

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
  • Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
  • Foot Orthotics 
  • Podiatric shoe inserts
All chargesAll charges
Benefit Description : Orthopedic and prosthetic devices High Option (You pay after deductible:)Standard Option (You pay after deductible:)

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

  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

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

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

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical and anesthesia services. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

50% of Plan Allowance50% of Plan Allowance
  • Hair prosthesis prescribed by a physician for hair loss resulting from radiation therapy, chemotherapy or certain other injuries, diseases, or treatment of a disease.
Nothing up to Plan lifetime maximum of $500Nothing up to Plan lifetime maximum of $500

Not covered:

  • Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
  • Lumbosacral supports
  • Corsets, trusses, elastic stockings, support hose, and other supportive devices
  • Replacement of prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s physical condition
  • All charges over $500 for hair prosthesis
All chargesAll charges
Benefit Description : Durable medical equipment (DME)High Option (You pay after deductible:)Standard Option (You pay after deductible:)

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

  • Oxygen systems and oxygen tanks
  • Dialysis equipment
  • Hospital beds (Clinitron and electric beds must be preauthorized)
  • Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
  • Crutches
  • Walkers
  • Speech generating devices
  • Blood glucose monitors
  • Audible prescription reading devices
  • Insulin pumps
  • C-Pap machine

50% of Plan Allowance

 

 

50% of Plan Allowance
  • Oxygen concentrators
  • Medically necessary accessories and supplies such as hoses, tubes, oxygen and ostomy supplies

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

Nothing

Nothing

Not covered:

  • Durable medical equipment, corrective appliances, prostheses and artificial aids, including supplies and accessories, are excluded when primarily used for convenience, comfort, or in the absence of an illness or injury. Routine periodic servicing, such as cleaning and regulating is not covered.
  • Replacement of durable medical equipment, prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s condition.
  • Bathroom equipment such as bathtub seats, benches, rails and lifts.
  • Home modifications such as stair glides, elevators and wheelchair ramps.
  • Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities.

All charges

All charges

Benefit Description : Home health servicesHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)
  • Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.  Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less.  The plan will allow up to 60 visits per member per calendar year. Your Plan Physician will periodically review the program for continuing appropriateness and need.
  • Services include oxygen therapy

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

$40 per visit

$45 per visit

Intravenous (IV) Infusion Therapy and medications

$40 per visit

$45 per visit

Not covered:

  • Nursing care requested by, or for the convenience of, the patient or the patient’s family
  • Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication
  • Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
  • Services provided by a family member or resident in the members home
  • Services rendered at any site other than the member’s home
  • Services rendered when the member is not homebound because of illness or injury
  • Private duty nursing services
  • Transportation
All chargesAll charges
Benefit Description : Chiropractic High Option (You pay after deductible:)Standard Option (You pay after deductible:)

Coverage is limited to 20 visits per calendar year. Services include:

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

$25 per office visit to a primary care physician

$40 per office visit to a specialist

$25 per office visit to a primary care physician

$45 per office visit to a specialist

Not covered:

Any services not listed above

All chargesAll charges
Benefit Description : Alternative treatmentsHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)

Biofeedback therapy for the treatment of certain conditions

  • Anesthesia
  • Pain relief

$25 per office visit to a primary care physician

$40 per office visit to a specialist

$25 per office visit to a primary care physician

$45 per office visit to a specialist

Not covered:

  • Acupuncture
  • Applied kinesiology
  • Aromatherapy
  • Craniosacral therapy
  • Hair analysis
  • Acupressure
  • Naturopathic or homeopathic services
  • Massage therapy
  • Hypnotherapy
  • Reflexology
All chargesAll charges
Benefit Description : Educational classes and programsHigh Option (You pay after deductible:)Standard Option (You pay after deductible:)

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

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

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

Nothing (no deductible) 

Nothing (no deductible) 

Coverage is provided for:

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

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

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

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

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.




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care.  It is your responsibility to verify that your physician has scheduled your surgery in a Plan facility.  We will not pay for services provided by a non-Plan provider or facility without prior authorization.
  • The deductible is $50 Self Only or $100 for Self Plus One or Self and Family enrollment for High Option and $100 Self Only or $200 for Self Plus One or Self and Family enrollment for Standard Option each calendar year. The deductible applies to all benefits in this section. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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. (except where noted otherwise).
  • A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to Section 3 for prior authorization information and to be sure which services require prior authorization.



Benefit Description : Surgical proceduresHigh Option (You pay after deductible )Standard Option (You pay after deductible )

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Removal of tumors and cysts
  • Normal pre- and post-operative care by the surgeon
  • Endoscopy procedures
  • Biopsy procedures
  • Voluntary sterilization (e.g.,vasectomy)
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Treatment of burns
  • Routine circumcision of a newborn
  • Insertion of internal prosthetic devices. See Section 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. 

$25 per office visit to a primary care physician

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care physician

$45 per office visit to a specialist

See section 5(c) for facility charges.

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.

$25 per office visit to a primary care physician

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care physician

$45 per office visit to a specialist

See section 5(c) for facility charges.

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

Nothing (no deductible)

Nothing (no deductible)

  • 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 page 24. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

$25 per office visit to a primary care physician

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care physician

$45 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

  • Reversal of voluntary surgically-induced sterilization
  • Surgery primarily for cosmetic purposes
  • Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
  • Routine treatment of conditions of the foot (see Foot care)
All chargesAll charges
Benefit Description : Reconstructive surgery High Option (You pay after deductible )Standard Option (You pay after 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 anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
  • 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 lymphedemas 
    • breast prostheses, and surgical bras (See Orthopedic and prosthetic devices in Section 5(a))

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

$25 per office visit to a primary care physician

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care physician

$45 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

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

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

  • Treatment of fractures of the jaws or facial bones;
  • Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
  • Removal of stones from salivary ducts;
  • Excision of leukoplakia or malignancies;
  • Medically necessary surgical treatment of TMJ (must be preauthorized)
  • Excision of cysts and incision of abscesses when done as independent procedures; and
  • Other surgical procedures that do not involve the teeth or their supporting structures
  • Removal of bony impacted wisdom teeth

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

$25 per office visit to a primary care physician

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care physician

$45 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges All charges
Benefit Description : Organ/tissue transplantsHigh Option (You pay after deductible )Standard Option (You pay after 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 page 24.

  • 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)

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

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

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

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

Blood or marrow stem cell transplants

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

The Plan extends coverage for the diagnoses as indicated below.

  • Allogeneic transplants for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin's lymphoma with reccurence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced neuroblastoma
    • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • 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 nonlymphocytic (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.

$40 per specialist visit
See section 5(c) for facility charges.

$45 per specialist visit
See section 5(c) for facility charges.

Mini-transplants performed in a clinical trial setting (non-myeloblative, 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

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

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

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

  • Allogeneic transplants for:
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Beta Thalassemia Major
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Sickle Cell anemia
  • Mini-transplants (non-myeloablative allogeneic, Reduced Intensity Conditioning or RIC) for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Breast cancer
    • Chronic lymphocytic leukemia
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Colon cancer
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Myelodysplasia/Myelodysplastic Syndromes
    • Myeloproliferative disorders (MPDs)
    • Non-small cell lung cancer
    • Ovarian cancer
    • Prostate cancer
    • Renal cell carcinoma
    • Sarcomas
    • Sickle cell anemia
  • Autologous Transplants for:
    • Advanced childhood kidney cancers
    • Advanced Ewing sarcoma
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Aggressive non-Hodgkin lymphomas
    • 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

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

National Transplant Program (NTP) - Transplants which are non-experimental or non-investigational are a covered benefit.  Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery.  The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures.  A transplant is non-experimental and non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate for 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 not be covered.

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

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

Clinical trials must meet the following criteria:

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

B. All of the following criteria must be met:

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

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

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

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

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

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

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

4. The member must:

a. Not be treated “off protocol,” and

b. Must actually be enrolled in the trial.

$40 per specialist visit

See section 5(c) for facility charges.

$45 per specialist visit

See section 5(c) for facility charges.

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Transplants not listed as covered
  • Travel expenses, lodging, and meals
All chargesAll charges
Benefit Description : AnesthesiaHigh Option (You pay after deductible )Standard Option (You pay after deductible )

Professional services provided in –

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

Nothing

See section 5(c) for facility charges.

15% of Plan Allowance

See section 5(c) for facility charges.

Professional services provided in –

  • Office

$25 per office visit to a primary care physician

$40 per office visit to a specialist

$25 per office visit to a primary care physician

$45 per office visit to a specialist




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility. It is your responsibility to verify your physician has arranged for your care in a Plan facility.  We will not pay for services provided by a non-Plan facility without prior authorization.
  • The deductible is $50 Self Only or $100 for Self Plus One or Self and Family enrollment for High Option and $100 Self Only or $200 for Self Plus One or Self and Family enrollment for Standard Option each calendar year.  The deductible applies to all benefits in this section. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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. (except where noted otherwise).
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 for prior authorization information and to be sure which services require prior authorization.
  • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.




Benefit Description : Inpatient hospital servicesHigh Option (You pay after deductible)Standard Option (You pay after deductible)

Room and board, such as

  • Private Ward, semiprivate, or intensive care accommodations
  • General nursing care
  • Meals and special diets
Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$200 per day up to a maximum of $1,000 per admission

15% of Plan Allowance

 

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
  • Take-home items
  • Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

$200 per day up to a maximum of $1,000 per admission

15% of Plan Allowance

Not covered:

  • Custodial care
  • Non-covered facilities, such as nursing homes, schools, rest cures, domiciliary or convalescent cares
  • Whole blood and concentrated blood cells not replaced by the member
  • Personal comfort items, such as phone, television, barber services, guest meals and beds
  • Private nursing care
All chargesAll charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You pay after deductible)Standard Option (You pay after 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
  • Administration of blood, blood plasma, and other biologicals
  • Blood products, derivatives and components, artificial blood products and biological serum
  • Pre-surgical testing
  • Dressings, casts, and sterile tray services
  • Medical supplies, including oxygen
  • Anesthetics and anesthesia service

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

$400 per visit

$650 per visit

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

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

*See below for exceptions

$40 per specialist visit

$45 per specialist visit

Complex diagnostic tests limited to:

  • CT scans, MRIs, MRAs, and electron beam scans
  • PET and SPECT scans
  • Angiography, and other procedures that require vascular catheterization and/or the injection of medication, imaging contrast, or other substance
  • Any radiological procedure that must be performed in conjunction with a diagnostic surgical procedure (for example: ultrasonic guidance procedures)
  • Diagnostic nuclear medicine, including provision of radiopharmaceuticals for diagnostic purposes
  • Genetic testing—diagnostic*

*Note:  These services need precertification.  See “Services requiring prior approval” on page 24.

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

$200 copay

$250 copay

Not covered:

  • Personal comfort items
  • Whole blood and concentrated red blood cells not replaced by the member
All chargesAll charges
Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHigh Option (You pay after deductible)Standard Option (You pay after deductible)

Skilled nursing facility (SNF) / Extended care benefits: 30 days per member per calendar year

  • Professional services – physicians and general nursing care
  • Medical supplies and medications
  • Medical equipment ordinarily provided by a skilled nursing facility
  • Room and board
Nothing after $200 per admission copay15% of Plan Allowance

Not covered:

  • Custodial care, personal, comfort or convenience items
All charges All charges
Benefit Description : Hospice careHigh Option (You pay after deductible)Standard Option (You pay after deductible)
  • Services for pain and symptom management
  • Short-term inpatient care and procedures necessary for pain control
  • Respite care may be provided only on an occasional basis and may not be provided longer than five days
  • Home visits made by a physician, nurse, home health aide, social worker or therapist with no limit on number of visits
  • General medical equipment and supplies related to the terminal illness

$5 copay

$15 copay

Not covered:

  • Independent nursing
  • Homemaker services
  • Specialized, customized equipment
All charges All charges
Benefit Description : AmbulanceHigh Option (You pay after deductible)Standard Option (You pay after deductible)

The plan 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

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

$100 copayment per trip$100 copayment per trip

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 require prior approval from the Plan.

All chargesAll charges



Section 5(d). Emergency Services/Accidents (High and Standard Options)

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 $50 Self Only or $100 for Self Plus One or Self and Family enrollment for High Option and $100 Self Only or $200 for Self Plus One or Self and Family enrollment for Standard Option each calendar year.  The deductible applies to all benefits in this section. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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. (except where noted otherwise).
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.



What is a medical emergency?

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





What to do in case of emergency:

Emergencies within our service area:

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world.  An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person’s health or with respect to a pregnant woman, the health of the woman and her unborn child.  

Whether you are in or out of an Altius HMO service area, we simply ask that you follow the guidelines below when you believe you need emergency care.

  • Call the local emergency hotline (e.g. 911) or go to the nearest emergency facility. For non-emergency services, care may be obtained from a retail clinic, a walk-in clinic, an urgent care center or by calling Teladoc.  If a delay would not be detrimental to your health, call your primary care physician.  Notify your primary care physician as soon as possible after receiving treatment.
  • After assessing and stabilizing your condition, the emergency facility should contact your primary care physician so he/she can assist the treating physician by supplying information about your medical history.
  • If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Altius as soon as possible.

Emergencies outside our service area:

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

If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or emergency problem does not qualify for coverage, it may be necessary to provide us with additional information. We will send you an Emergency Room Notification Report to complete, or a Member Services representative can take this information by phone.




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

$25 per PCP visit

$40 per specialist visit

$25 per PCP visit

$45 per specialist visit

  • Emergency or urgent care at an urgent care center

$40 copayment per urgent care center visit

$40 copayment per urgent care center visit

  • Emergency care as an outpatient at a hospital, (Emergency Room) including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

$250 copayment per visit

$250 copayment per visit

Not covered:

  • Elective care or non-emergency care in a hospital emergency room
  • Follow-up care in a hospital emergency room, unless we have given prior authorization

All charges

All charges

Benefit Description : Emergency outside our service areaHigh Option (You pay after deductible )Standard Option (You pay after deductible )
  • Emergency or urgent care at a doctor’s office

$25 per PCP visit

$40 per specialist visit

$25 per PCP visit

$45 per specialist visit

  • Emergency or urgent care at an urgent care center

$40 copayment per urgent care center visit

$40 copayment per urgent care center visit

  • Emergency care as an outpatient at a hospital, (Emergency Room) including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

$250 copayment per visit

$250 copayment per visit

Not covered:

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

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.

$30 per consult$40 per consult
Benefit Description : AmbulanceHigh Option (You pay after deductible )Standard Option (You pay after deductible )

The plan 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

$100 copayment per trip$100 copayment per trip

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 chargesAll charges



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

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 $50 for Self Only or $100 for Self Plus One or Self and Family enrollment for High Option and $100 for Self Only or $200 for Self Plus One or Self and Family enrollment for Standard Option each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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. (except where noted otherwise).  
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • YOU MUST GET PREAUTHORIZATION FOR CERTAIN SERVICES. Benefits are payable only when we determine the care is clinically appropriate to treat your condition. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan. Please see Section 3 of this brochure for a list of services that require preauthorization. 
  • The Plan 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 behavioral health care services that are covered under your specific plan by calling Member Services at 800-537-9384.  A referral from your PCP is not necessary to access behavioral health care but your PCP may assist in coordinating your care.
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
  • OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.



Benefit Description : Professional servicesHigh Option (You Pay after deductible)Standard Option (You Pay after 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.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

$25 per office visit

$25 per office visit

  • Telemedicine Behavioral Health consult

$25 per office visit

$25 per office visit

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

$25 per office visit

$25 per office visit

Benefit Description : Applied Behavior Analysis (ABA)High Option (You Pay after deductible)Standard Option (You Pay after deductible)

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

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

Note: Requires Precertification. See “Services requiring our prior approval” on page 24. You are responsible for ensuring that we are asked to precertify your care.  You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

$25 per visit

$25 per visit

Benefit Description : DiagnosticHigh Option (You Pay after deductible)Standard Option (You Pay after 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

$25 per office visit

$25 per office visit

Benefit Description : Inpatient hospital or other covered facilityHigh Option (You Pay after deductible)Standard Option (You Pay after 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

$200 per day up to a maximum of $1,000 per admission

15% of Plan Allowance
Benefit Description : Outpatient hospital or other covered facilityHigh Option (You Pay after deductible)Standard Option (You Pay after 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)

$25 per office visit

$25 per office visit

Benefit Description : Not CoveredHigh Option (You Pay after deductible)Standard Option (You Pay after deductible)
  • Educational services for treatment of behavioral disorders
  • Services in half-way houses
All chargesAll charges



Section 5(f). Prescription Drug Benefits (High and Standard Options)

Important things you should keep in mind about these benefits:

  • This is a five tier open formulary pharmacy plan, Advanced Control Formulary. The formulary is a list of drugs that your health plan covers.  

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

    • Preferred generic
    • Preferred brand
    • Non-preferred generic and brand
    • Preferred specialty
    • Non-preferred specialty
  • We cover prescribed drugs and medications, as described in the chart beginning on the next page.
  • We have no calendar year deductible for Prescription drugs.
  • 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/authorization 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.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. Upon approval by the Plan, the prescription is covered for the current calendar year or a specified time period, whichever is less.



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

  • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/ or certified providers with prescriptive authority prescribing within their scope of practice.
  • Where you can obtain them. You may fill non-emergency prescriptions at a participating Plan retail pharmacy or by mail order for 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, and for a 31-day up to a 90-day supply of medication for two (2) copays. In no event will the copay exceed the cost of the prescription drug. Please call Member Services at 800-537-9384 for more details on how to use the mail order program. Mail order is not available for drugs and medications ordered through a network Specialty Pharmacy. Prescriptions ordered through a network Specialty Pharmacy are only filled for up to a 30-day supply due to the nature of these prescriptions. In an emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. For retail pharmacy transactions, you must present your Member ID card at the point of sale for coverage. If you obtain an emergency prescription at a pharmacy that does not participate with the plan, you will need to pay the pharmacy the full price of the prescription and submit a claim for reimbursement subject to the terms and conditions of the plan.
  • We use a formulary. The formulary is a list of drugs that your Plan covers. Drugs are prescribed by Plan doctors and dispensed in accordance with the 2021 Pharmacy Drug(Formulary) Guide. Certain drugs require your doctor to get precertification or step therapy from the Plan before they can be covered under the Plan. Your prescription drug plan includes drugs listed in the 2021 Pharmacy Drug (Formulary) Guide. Prescription drugs listed on the formulary exclusions list are excluded unless a medical exception is approved by the Plan. If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at www.aetnafeds.com to review our 2021 Pharmacy Drug (Formulary) Guide or call 800-537-9384.
  • Drugs not on the formulary. Formularies are developed and reviewed by the CVS Caremark Pharmacy and Therapeutics Committee, comprised of physicians, pharmacists and other clinicians that review drugs for inclusion in the formulary. They consider the drug’s effectiveness and safety in their evaluation. While most of the drugs on the non-formulary list are brand drugs, some generic drugs also may be on the non-formulary list. For example, this may happen when brand medications lose their patent and the FDA has granted a period of exclusivity to specific generic manufacturers. When this occurs, the price of the generic drug may not decrease as you might think most generic drugs do. This period of exclusivity usually ranges between 3-6 months. Once this time period expires, competition from other generic manufacturers will generally occur and this helps lower the price of the drug and this may lead the Plan to re-evaluate the generic for possible inclusion on the formulary. We will place some of these generic drugs that are granted a period of exclusivity on our non-formulary list, which requires the highest copay level. Remember, a generic equivalent will be dispensed, if available, unless your physician specifically requires a brand name and writes "Dispense as Written" (DAW) on the prescription, so discuss this with your doctor.
  • Choose generics. The Plan requires the use of generics if a generic drug is available. If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance* unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained from the Plan. Generics contain the same active ingredients in the same amounts as their brand name counterparts and have been approved by the FDA. By using generic drugs, you will see cost savings, without jeopardizing clinical outcome or compromising quality. * The differential/penalty will not apply to plan accumulators (example: 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.
  • These are the dispensing limitations. Prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy or by mail order may be dispensed for 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, and a 31-day up to a 90-day supply of medication for two copays. In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name.

    In the event that a member is called to active military duty and requires coverage under their prescription plan benefits of an additional filing of their medication(s) prior to departure, their pharmacist will need to contact the plan. Coverage of additional prescriptions will only be allowed if there are refills remaining on the member's current prescription or a new prescription has been issued by their physician. The member is responsible for the applicable copayment for the additional prescription.
  • The Plan allows coverage of a medication refill when at least 80% of the previous prescription, according to the physician’s prescribed directions, has been utilized. For a 30-day supply of medication, this provision would allow a prescription refill to be covered 24 days after the last filling, thereby allowing a member to have an additional supply of their medication, in case of emergency.
  • When you do have to file a claim. Send your itemized bill(s) to: Aetna, Pharmacy Management, P.O. Box 52444, Phoenix, AZ 85072-2444.

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

  • A generic equivalent may be dispensed if it is available, and where allowed by law.
  • Mail order pharmacy. Generally the drugs available through mail order are maintenance drugs that you take on a regular basis for a chronic or long-term medical condition. Outpatient prescription drugs are covered when dispensed by a network mail order pharmacy or a CVS pharmacy®. Each prescription is limited to a maximum 90-day supply. Prescriptions for less than a 30-day supply or more than a 90-day supply are not eligible for coverage when dispensed by a network mail order pharmacy. 
  • Specialty drugs. Specialty drugs are medications that treat complex, chronic diseases which includes select oral, injectable and infused medications. The first fill including all subsequent refills 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 office visit copay. If you obtain the prescribed medications directly from a network specialty pharmacy. You will pay the applicable copay as outlined in Section 5(f) of this brochure.

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



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

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

  • Drugs approved by the U.S. Food and Drug Administration for which a prescription is required by Federal law, except those listed as Not covered
  • Diabetic supplies limited to:
    • Lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips
    • Insulin
    • Disposable needles and syringes needed to inject covered prescribed 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 or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

$7 per covered generic formulary drug;

$40 per covered brand name formulary drug;

40% per covered non-formulary (generic or brand name) drug up to $240 maximum

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

$7 per covered generic formulary drug;

$80 per covered brand name formulary drug;

40% per covered non-formulary (generic or brand name) drug up to $720 maximum

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

$7 per covered generic formulary drug;

$50 per covered brand name formulary drug;

50% per covered non-formulary (generic or brand name) drug up to $240 maximum

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

$7 per covered generic formulary drug;

$100 per covered brand name formulary drug;

50% per covered non-formulary (generic or brand name) drug up to $720 maximum

Women's contraceptive drugs and devices

  • Generic oral contraceptives on our formulary list
  • Generic emergency contraception, including 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

Nothing

Nothing

  • 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 or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

$40 per covered brand name formulary drug;

40% per covered non-formulary (generic or brand name) drug up to $240 maximum

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

$80 per covered brand name formulary drug;

40% per covered non-formulary (generic or brand name) drug up to $720 maximum

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

$50 per covered brand name formulary drug;

50% per covered non-formulary (generic or brand name) drug up to $240 maximum

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

$100 per covered brand name formulary drug;

50% per covered non-formulary (generic or brand name) drug up to $720 maximum

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 69, Specialty Drugs for more information or visit: www.aetnafeds.com/pharmacy.

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

Preferred: 30% of Plan Allowance

Non-preferred (non- formulary): 50% of Plan Allowance

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

Preferred: 30% of Plan Allowance

Non-preferred (non- formulary): 50% of Plan Allowance

Limited benefits:

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

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

$7 per covered generic formulary drug;

$40 per covered brand name formulary drug;

40% per covered non-formulary (generic or brand name) drug up to $240 maximum

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

$7 per covered generic formulary drug;

$50 per covered brand name formulary drug;

50% per covered non-formulary (generic or brand name) drug up to $240 maximum

Benefit Description : Preventive care medicationsHigh Option (You pay)Standard Option (You pay)

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

Drugs and supplements are covered without cost-share which includes some over-the-counter 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 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.

NothingNothing

Not covered:

  • Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law or covered by the plan.
  • Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
  • Vitamins, unless otherwise stated (including prescription vitamins), nutritional supplements, and any food item not listed as a covered benefit, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition except for nutritional formulas for the treatment of phenylketonuria branched chain ketonuria, galactosemia and homocystinuria when administered under the direction of a Plan doctor (please see Durable Medical Equipment section on page 43).
  • Medical supplies such as dressings and antiseptics
  • Lost, stolen or damaged drugs
  • Drugs for cosmetic purposes
  • Fertility drugs
  • Drugs to enhance athletic performance
  • Drugs used for the purpose of weight reduction (i.e., appetite suppressants)
  • Prophylactic drugs including, but not limited to, anti-malarials for travel
  • Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
  • Compounded thyroid hormone therapy

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See page 45).  OTC drugs will not be covered unless you have a prescription and that prescription is presented at the pharmacy and processed through our pharmacy claim system.

All charges

All charges




Section 5(g). Dental Benefits (High and Standard Options)

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.
  • Deductible does not apply to dental benefits.
  • 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. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The Standard Option includes accidental dental injury benefits only.  There are no other dental benefits for the Standard Option.



Benefit Description : Accidental injury benefitHigh Option (You Pay)Standard Option (You Pay)
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.

$25 per office visit to a primary care physician

$40 per office visit to a specialist

See section 5(c) for facility charges.

$25 per office visit to a primary care physician

$45 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

  • Implants
All charges All charges



Dental benefits


Note:  This is not a complete list of covered dental services. To determine if other services are covered that are not listed, call Customer Service and provide the appropriate dental codes or service descriptions obtained from your dentist's office.


                                                                                                                                      Dental benefits continued on next page




Dental Benefits : ServiceHigh Option (You Pay)

Oral evaluation

    • Periodic oral examination ­– one per member every six months
    • Limited oral evaluation – problem focused
    • Comprehensive oral evaluation
Nothing
    • Comprehensive periodontal evaluation
Nothing

Radiographs

    • Intraoral full series X-rays – one per member every three years
    • Bitewing X-rays
    • Panoramic X-ray – one per member every three years
Nothing

Preventive

  • Prophylaxis and fluoride treatment (child) – one per member every six months
  • Prophylaxis (adult) – one per member every six months
Nothing
  • Sealant – per tooth (through age 14)
Nothing

Emergency treatment - During office hours

  • Palliative treatment of dental pain
40%

Restorative

Routine fillings – Amalgam or Resin-based composite for permanent or primary teeth

Amalgam

    • 1 surface
40%
    • 2 surfaces
40%
    • 3 surfaces
40%
    • 4 or more surfaces
40%

Restorative

Routine fillings – Amalgam or Resin-based composite for permanent or primary teeth

Resin-based composite – anterior

    • 1 surface
40%
    • 2 surfaces
40%
    • 3 surfaces
40%
    • 4 or more surfaces
40%

Restorative

Routine fillings – Amalgam or Resin-based composite for permanent or primary teeth

Resin-based composite – posterior

    • 1 surface
40%
    • 2 surfaces
40%
    • 3 surfaces
40%
    • 4 or more surfaces

 

 

40%

Periodontics

Periodontal scaling and root planing – four or more teeth per quadrant

40%
Periodontal scaling and root planing – one to three teeth per quadrant40%
Gingivectomy or gingivoplasty – per quadrant40%
Gingivectomy or gingivoplasty – per tooth (to three teeth)40%
Osseous surgery – four or more teeth per quadrant60%
Osseous surgery – one to three teeth per quadrant60%
Localized delivery of antimicrobial agents40%
Periodontal maintenance40%

Oral surgery

Extractions (routine)

40%
Surgical removal of erupted tooth40%
Impacted teeth – soft tissue40%
Impacted teeth – partial bony60%
Impacted teeth – full bony60%

Endodontics

Pulp cap

40%
Vital pulpotomy40%
Root canal, single canal40%
    • two canals
40%
    • three canals
60%

Crowns – Limited to six crowns per member per year

Crown build up with pins

60%
Preformed post and build up60%
Stainless steel crown60%
Crown – porcelain fused to metal60%
Crown – porcelain fused to precious metal60%
Recement crown40%
Complete denture (upper or lower)60%
Partial denture (upper or lower)60%
Denture adjustment60%
Add tooth to existing partial denture60%
Add clasp to existing partial denture60%
Interim complete denture (upper or lower)60%
Interim partial denture/stayplate (upper or lower)60%
Replace missing or broken teeth, full or partial dentures, one involved tooth60%
    • Each additional tooth
60%
Reline denture (upper or lower) – chairside60%
Reline denture (upper or lower) – lab60%

Preventive appliances

Space maintainer – unilateral

Nothing
Space maintainer – bilateralNothing

The following services are limited:

  • Replacement of prosthetic appliances less than five years old is covered only when good dental care dictates and such replacement is prescribed by a Plan dentist.
  • Single unit gold restorations and crowns are covered only when the tooth cannot be adequately restored with other restorative materials.

Not covered:

  • Implants
  • Bridges
  • Surgical grafting procedures
  • Treatment for developmental malformations such as enamel hypoplasia and fluorosis (brown and white stains on teeth)
  • Maxillary and mandibular malformations and anodontia
  • General anesthetic
  • Cosmetic or orthodontic treatment
  • Full mouth rehabilitation, periodontal splints, restoration of tooth structure lost from attrition and restoration for misalignment of the teeth
  • Dental treatment for temporomandibular (jaw) joint disorders and related diseases
  • Replacement of lost or stolen dentures, bridges or other dental appliances
  • Topical application of fluoride for adults
All charges



Section 5. High Deductible Health Plan Benefits (HDHP)

See page 21 for how our benefits changed this year and page 160 for a benefits summary.




(Page numbers solely appear in the printed brochure)

Table of Content



Section 5. High Deductible Health Plan Overview (HDHP)

This Plan offers a High Deductible Health Plan (HDHP). The HDHP 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.

HDHP Section 5, which describes the HDHP 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 benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about HDHP benefits, contact us at 800-537-9384 or on our website at www.aetnafeds.com

Our HDHP option provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you build savings for future medical expenses. The Plan gives you greater control over how you use your health care benefits.

When you enroll in this HDHP, we establish either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) for you. We automatically pass through a portion of the total health Plan premium to your HSA or credit an equal amount to your HRA based upon your eligibility. Your full HRA credit will be available on your effective date of enrollment.

With this Plan, 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. You can choose to use funds available in your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket, allowing your savings to continue to grow.

This HDHP includes five key components: preventive care; traditional medical coverage health care that is subject to the deductible; savings; catastrophic protection for out-of-pocket expenses; and health education resources and account management tools such as online, interactive health and benefits information tools to help you make more informed health decisions.




TermDefinition
  • Preventive care

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations, tobacco/E-cigarettes cessation programs, obesity weight loss programs, disease management and wellness programs. These services are covered at 100% if you use a network provider and the services are described in Section 5 Preventive care. You do not have to meet the deductible before using these services. Preventive care does not reduce your HRA nor do you need to use your HSA for in-network preventive care.

  • Traditional medical coverage

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5.  You typically pay $20 per office visit to a primary care physician, $30 per office visit to a specialist. The Plan typically pays 90% for home care and hospital care; you typically pay 10% of the Plan allowance.

Covered services include:

  • Medical services and supplies provided by physicians and other health care professionals
  • Surgical and anesthesia services provided by physicians and other health care professionals
  • Hospital services; other facility or ambulance services
  • Emergency services/accidents
  • Mental health and substance abuse benefits
  • Prescription drug benefits
  • Dental benefits for services related to an accidental injury.
  • Savings
Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see  for more details).

Health Savings Accounts (HSAs)

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Services (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan.  In 2021, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $62.50 per month for a Self Only enrollment or $125.00 per month for a Self Plus One enrollment or $125.00 per month for a Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,600 for an individual and $7,200 for a family.  See maximum contribution information on page 83. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

  • PayFlex Systems USA, Inc., an Aetna company, provides a debit card and record- keeping services. PayFlex Systems USA, Inc. is the custodian for the HSA accounts.
  • Your contributions to the HSA are tax deductible. (State taxes apply in California, Alabama and New Jersey)
  • You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).
  • Your HSA earns tax-free interest. or any investment gains through a choice of voluntary investment options. (New Hampshire and Tennessee do tax dividends and earnings on HSA’s)
  • You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS publication 502 for a complete list of eligible expenses. A link to this publication can also be found at www.aetnafeds.com.)
  • Your unused HSA funds and interest accumulate from year to year.
  • It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire.
  • When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a Health Care Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by an HCFSA health care flexible spending account this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you.

Health Reimbursement Arrangements (HRA)

If you are not eligible for an HSA, for example you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA.

If we determine that you are ineligible for an HSA, we will notify you by letter and provide an HRA for you.

In 2021, we will give you an HRA credit of $750 per year for a Self Only enrollment or $1,500 per year for a Self Plus One enrollment or $1,500 per year for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible.

HRA features include:

  • For our HDHP option, the HRA is administered by Aetna Life Insurance Company. 
  • Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment.
  • Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP.
  • Unused credits carryover from year to year.
  • HRA credit does not earn interest.
  • HRA credit is forfeited if you leave Federal employment or switch health insurance plans.
  • An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements.
  • 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 enrollment, $12,000 per Self Plus One enrollment or $12,000 per 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 non-covered expenses). Refer to Section 4 Your catastrophic protection out-of-pocket maximum for more details and HDHP Section 5 Traditional medical coverage subject to the deductible for more details.

  • Health education resources and account management tools
HDHP Section 5(i) describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.



Section 5. Savings – HSAs and HRAs (HDHP)

TermDefinition 1Definition 2
Feature ComparisonHealth Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are
ineligible for an HSA

Administrator

The Plan will establish an HSA for you with PayFlex Systems USA, Inc. an Aetna company (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS).

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

800-537-9384 or www.aetnafeds.com

Aetna Life Insurance Company is the HRA fiduciary for this Plan.

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

800-537-9384 or www.aetnafeds.com

Fees

There is no HSA set-up fee.

The administrative fee is covered in the premium while the member is covered under the HDHP.

If you are no longer covered under the HDHP, there is a $5 monthly administrative fee that will be deducted from your HSA account every month.

Members will be subject to the administrative fee if they are enrolled but no longer eligible for contributions and enrolled in the HRA.

None

Eligibility

You must:

  • Enroll in this HDHP
  • Have no other health insurance coverage
  • Not be enrolled in Medicare
  • Not be claimed as a dependent on someone else’s tax return
  • Not currently receiving VA benefits or services (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits in the last three (3) months 
  • Complete and return all banking paperwork

Eligibility for contributions is determined on the first day of the month following your effective date of enrollment and will be prorated for length of enrollment.

You must enroll in this HDHP.

Eligibility is determined on the first day of the month following your effective day of enrollment and will be prorated for length of enrollment.

Funding

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month. Premium pass through contributions are based on the effective date of your enrollment in the HDHP.

Note: If your effective date in the HDHP is after the 1st of the month, the earliest your HSA will be established is the 1st of the following month.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, Etc.)

You may contribute to your HSA by submitting a contributions coupon or setting up an electronic funds transfer from your checking or saving account up to the maximum allowed. The deadline for HSA contributions is April 15 following the year for which contributions are made. When making contributions for previous tax year, use the Tax Year Designation Change for Contributions to HSA form. You can obtain additional HSA forms by logging into the Member Website website at www.aetnafeds.com.

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for length of enrollment. The entire amount of your HRA will be available to you upon your enrollment.

  • Self Only enrollment

For 2021, a monthly premium pass through of $62.50 will be made by the HDHP directly into your HSA each month.

For 2021, your HRA annual credit is $750 (prorated for mid-year enrollment).

  • Self Plus One enrollment

For 2021, a monthly premium pass through of $125.00 will be made by the HDHP directly into your HSA each month.

For 2021, your HRA annual credit is $1,500 (prorated for mid-year enrollment).

  • Self and Family
    enrollment

For 2021, a monthly premium pass through of $125.00 will be made by the HDHP directly into your HSA each month.

For 2021, your HRA annual credit is $1,500 (prorated for mid-year enrollment).

Contributions/credits

The maximum that can be contributed to your HSA is an annual contribution of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $3,600 for individual Self Only coverage and $7,200 for a Self Plus One and Self and Family coverage.

If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your H.S.A. The allowable catch-up contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS. 

Note: Annual premium pass through contributions will be forfeited if you do not open an H.S.A by 12/31 of that plan year.

You are eligible to fund your account up to the maximum contributions limit set by the IRS even if you have partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA.  If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death and disability.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Catch-up contribution discussed on page 87.

The full HRA credit will be available, subject to proration, on the effective date of enrollment. The HRA does not earn interest.

  • Self Only enrollment

You may make an annual maximum contribution of $2,850.

You cannot contribute to the HRA.

  • Self Plus One enrollment

You may make an annual maximum contribution of $5,700.

You cannot contribute to the HRA.

  • Self and Family enrollment

You may make an annual maximum contribution of $5,700.

You cannot contribute to the HRA.

Access funds

You can access your HSA by the following methods:

  • Debit card - The Debit Card must be activated in order to have access to HSA Funds, customer service and online information.
  • The online employee portal.
  • Connected Claims Option - Connected claims is a fast and easy way to pay out- of-pocket health expenses from your HSA. If you are a member of an Aetna HDHP and enrolled in an Aetna HSA you can elect to have your claims sent directly to your HSA to pay for qualified out-of-pocket expenses, paying the doctor directly, without having to use your PayFlex Aetna HSA MasterCard debit card.
  • Direct Deposit for HSA Reimbursement - Reimbursements can now be sent electronically to personal checking or savings accounts. You can access this feature from the employee portal.

For qualified medical expenses under your HDHP, you will be automatically reimbursed when claims are submitted through the HDHP. For expenses not covered by the HDHP, such as dental services, a reimbursement form will be sent to you upon your request.

Distributions/withdrawals

  • Medical

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA.

Your HSA is established the first of the month following the effective date of your enrollment in this HDHP. For most Federal enrollees (those not paid on a monthly basis), the HDHP becomes effective the first pay period in January 2021. If the HDHP is effective on a date other than the first of the month, the earliest date medical expenses will be allowable is the first of the next month. If you were covered under the HDHP in 2020 and remain enrolled in this HDHP, your medical expenses incurred January 1, 2021 or later, will be allowable.

If you incur a medical expense between your HDHP effective date but before your HSA is effective, you will not be able to use your HSA to reimburse yourself for those expenses.

Note: Plan contributions are typically deposited around the middle of each month.

See IRS Publication 502 for a list of eligible medical expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.  You must submit these expenses with a claim form (available on our website www.aetnafeds.com) for reimbursement.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a list of eligible medical expenses.  Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable.  Most other types of medical insurance premiums are not reimbursable.

  • Non-medical

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Not applicable – distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Availability of funds

Funds are not available for withdrawal until all the following steps are completed:

  • Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change),
  • The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA, and  
  • The fiduciary sends you HSA paperwork for you to complete and the fiduciary receives the completed paperwork back from you.
  • After the plan administrator receives enrollment and contributions from OPM and your HSA has been created by PayFlex Systems USA, Inc. and funded, the enrollee can withdraw funds up to the amount contributed for any expenses incurred on or after the date the HSA was initially established.

Funds are not available until:

  • Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change); and
  • The entire amount of your HRA will be available to you upon your enrollment in the HDHP.  (The HRA amount will be pro-rated based on the effective date of coverage.)
Account ownerFEHB enrolleeAetna Life Insurance Company
Portable

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.
Annual rollover Yes, accumulates without a maximum cap.Yes, accumulates without a maximum cap.



Fees for Federal Employees Health Benefit Program




TermDefinition

Monthly Account Maintenance

No charge

Returned Deposit Check

$25.00 per returned deposit check

Checks Returned for Non-sufficient Funds

$25.00 per returned check

Stop Payment of Check

$25.00 per stopped check

Returned EFT Deposit*

$25.00 per EFT deposit return

Account Closing

No charge

Replacement of Lost/Stolen HSA Debit Card

No charge

Paper Statement

$1.50 - available online at no charge

Investment Fee

You can open an investment account and you will be charged monthly at .02% of your investment account balance.

Trustee Transfer Fee

$25.00 per transfer




*Electronic Funds Transfer (EFT)




If You Have an HSA (HDHP)

TermDefinition
  • Contributions

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction). You receive tax advantages in any case. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective data is after January 1st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of year of your first year of eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

  • Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional "catch-up" contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

Spouse catch-up contributions must be established in a separate HSA account from that of the employee. Please contact your plan administrator for details.

  • If you die
If you have not named beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA becomes part of your taxable estate.
  • Qualified expenses

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.” Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA.  Also, insurance premiums are reimbursable under limited circumstances.

  • Non-qualified expenses
You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
  • Tracking your HSA balance

You can view account activity such as the “premium pass through,” withdrawals, and interest earned on your account, as well as account balances online on Aetna Member Website. You can also request a paper monthly activity statement at an additional charge - $1.50 per month.

  • Minimum reimbursements from your HSA

There is no minimum withdrawal or distribution amount.

Investment Options

Participation in voluntary investment options is entirely optional and neither Aetna nor PayFlex Systems USA, Inc. is or will be acting in the capacity of a registered investment advisor.

Account holders who exceed the minimum required balance of $1,000 in their HSA cash account, will have a number of different investment options to choose from in 2021 that will be offered by different organizations that have been selected by PayFlex Systems USA, Inc. Balances in these investment options may fluctuate up or down and will not be insured by the FDIC or other government agencies.

PayFlex Systems USA, Inc. will make available HSA investment options, as defined below, to account holders who exceed the minimum required balance of $1,000 in their HSA cash account. (Investment options are subject to change).

These funds are distributed through BNY Mellon and are not offered or insured by

PayFlex Systems USA, Inc. or BNY Mellon. Participation in these options will be entirely optional, and neither PayFlex Systems USA, Inc. or BNY Mellon is or will be acting in the capacity of a registered investment advisor with respect to these options. Balances in the funds may fluctuate and will not be insured by the FDIC or other government agency.

Investment Options

Equity funds

  • JPMorgan Large Cap Growth Fund - Select Class
  • Schwab Fundamental US Large Company Index Fund
  • Davis New York Venture Fund Class Y
  • Vanguard 500 Index Admiral
  • Vanguard Dividend Appreciation Index Admiral
  • Invesco-Oppenheimer Main St Fund® CIY
  • Parnassas Mid Cap Fund Institutional Shares
  • American Century Investments® Mid Cap Value Fund Class 1
  • Artisan Small Cap Fund Institutional Shares
  • Vanguard Small-Cap Index Admiral
  • Dodge & Cox International Stock Fund
  • Thornburg International Value Fund Class I
  • Vanguard Developed Markets Index Admiral
  • Vanguard Emerging Markets Stock Index Admiral

Bond Funds

  • Dodge & Cox Income Fund
  • MetWest Total Return Bond Fund Class M

Other Funds

  • American Funds 2020 Target Date Retire R6
  • American Funds 2025 Target Date Retire R6
  • American Funds 2030 Target Date Retire R6
  • American Funds 2035 Target Date Retire R6
  • American Funds 2040 Target Date Retire R6
  • American Funds 2045 Target Date Retire R6
  • American Funds 2050 Target Date Retire R6
  • American Funds 2055 Target Date Retire R6
  • American Funds 2060 Target Date Retire R6
  • Vanguard LifeStrategy Conservative Growth Investor
  • Vanguard LifeStrategy Moderate Growth Investor



If You Have an HRA (HDHP)

TermDefinition
  • Why an HRA is established
If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you become ineligible to contribute to an HSA.
  • How an HRA differs

Please review the chart on page 82 which details the differences between an HRA and an HSA. The major differences are:

  • you cannot make contributions to an HRA
  • funds are forfeited if you leave the HDHP
  • an HRA does not earn interest
  • HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP. HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP. FEHB law does not permit qualified medical expenses to include 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.



Section 5. Preventive Care (HDHP)

Important things you should keep in mind about these benefits:

  • Plan physicians must provide or arrange your care. You are responsible for ensuring that your provider is a Plan provider.
  • 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.
  • Preventive care services listed in this section are not subject to the deductible. The Plan pays 100% for these preventive care services.
  • For all other covered expenses, please see Section 5 – Traditional medical coverage subject to the deductible.
  • 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 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 Funds.
  • 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 PHYSICIAN MUST OBTAIN PRIOR AUTHORIZATION FOR CERTAIN SERVICES, SUPPLIES, AND DRUGS. Please refer to Section 3 for prior authorization information and to be sure which services require prior authorization.




Benefit Description : Preventive care, adultHDHP (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/

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

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

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

Nothing

Routine mammogram — covered for women as follows:

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

 

Nothing

Not covered

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

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

  • Well-child care charges for routine examinations, immunizations and care (up to age 26)
    • 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 26
  • Examinations such as:
    • Vision Screening through age 17 to determine the need for vision correction
    • Hearing exams through age 17 to determine the need for hearing correction
    • Routine examinations done on the day of immunizations (up to age 26)

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

Nothing

Not covered

  • Physical exams and 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 (HDHP)

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.
  • Plan physicians must provide or arrange your care. You are responsible for ensuring that your provider is a Plan provider. When applicable, you must use Plan facilities. You are responsible for verifying that your provider has arranged for your surgery or hospitalization in a Plan facility. We will not pay for services provided by a non-Plan provider or facility without our prior authorization.
  • Preventive care services listed in the previous section are covered at 100% (see page 91) and are not subject to the calendar year deductible.
  • The deductible is $1,400 per person $2,800 per Self Plus One enrollment, or $2,800 per Self and Family enrollment each calendar year. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
  • Under Traditional medical coverage, you are responsible for your coinsurance and copayments for covered expenses.
  • 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 per person, $12,000 per Self Plus One enrollment or $12,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. 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 non-covered expenses). 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 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 physician must obtain prior authorization for some services, supplies, and drugs. Please refer to Section 3 for prior authorization information and to be sure which services require prior authorization.



Benefit Description : Deductible before Traditional medical coverage beginsHDHP (You pay After the calendar year deductible… )
The deductible applies to almost all benefits in this Section. In the You pay column, we say “No deductible” when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,400 per person, $2,800 per Self Plus One enrollment or $2,800 per Self and Family enrollment.

After you meet the deductible, we pay the allowable charge (less your coinsurance or copayment) until you meet the annual catastrophic out-of-pocket maximum.After you meet the deductible, you pay the indicated coinsurance or copayments for covered services. You may choose to pay the coinsurance and copayments from your HSA or HRA, or you can pay for them out-of-pocket.



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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care. You are responsible for ensuring that your provider is a Plan provider.
  • The deductible is $1,400 for Self Only enrollment, $2,800 per Self Plus One enrollment, or $2,800 for a Self and Family enrollment each calendar year.  Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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.
  • After you have satisfied your deductible, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses.
  • 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 PHYSICIAL MUST OBTAIN PRIOR AUTHORIZATION FOR SOME SERVICES, SUPPLIES, AND DRUGS. Please refer to Section 3 for prior authorization information and to be sure which services require prior authorization.




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

Professional services of physicians

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

$20 per office visit to a primary care physician

$30 per office visit to a specialist

  • In an urgent care center
$30 per visit
  • During a hospital stay
  • In a skilled nursing facility
10% of Plan Allowance
Benefit Description : Telehealth servicesHDHP (You pay After the calendar year deductible… )
  • Teladoc

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).

$30 per consult
Benefit Description : Lab, X-ray and other diagnostic testsHDHP (You pay After the calendar year deductible… )

Minor diagnostic tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine Pap tests
  • Pathology
  • X-rays
  • Non-routine mammograms
  • Ultrasound
  • Electrocardiogram and EEG
$30 copay

Major diagnostic labs and radiology tests, such as:

  • CT scans, MRIs, MRAs, and electron beam scans
  • PET and SPECT scans
  • Angiography, and other procedures that require vascular catheterization and/or the injection of medication, imaging contrast, or other substance
  • Any radiological procedure that must be performed in conjunction with a diagnostic surgical procedure (for example: ultrasonic guidance procedures)
  • Diagnostic nuclear medicine, including provision of radiopharmaceuticals for diagnostic purposes
  • Cytogenetic studies

$175 copay

Benefit Description : Maternity careHDHP (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.

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.

 

No copay (no deductible) for routine prenatal care or the first postpartum care visit

10% of Plan Allowance

Screening for gestational diabetes for pregnant women

Nothing (no deductible)

Breastfeeding support, supplies and counseling for each birth

Nothing (no deductible)

Not covered:

  • Routine sonograms to determine fetal age, size or sex
  • Home delivery
All charges
Benefit Description : Family planning HDHP (You pay After the calendar year deductible… )

A range of voluntary family planning services, such as:

  • Contraceptive counseling on an annual basis
  • Voluntary sterilization (See Surgical procedures Section 5(b))
  • Surgically implanted contraceptives
  • Intrauterine devices (IUDs)

Nothing for women

For men:

$20 per PCP visit

$30 for Specialist visit

  • Generic injectable contraceptive drugs 

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

Nothing

Not covered:

  • Reversal of voluntary surgical sterilization
  • Predictive genetic testing and/or genetic counseling.
All charges
Benefit Description : Infertility servicesHDHP (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.
50% of Plan Allowance

Not covered:

  • Any assisted reproductive technology (ART) procedure or services related to such procedures, including but not limited to in-vitro fertilization, gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and intra-cytoplasmic sperm injection (ICSI) or
  • Artificial insemination (AI):
        – 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 voluntary, surgically-induced sterility 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
  • The purchase, freezing and storage of donor sperm and donor embryos.
  • 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 careHDHP (You pay After the calendar year deductible… )
  • Testing and treatment

$20 per office visit to a primary care physician

$30 per office visit to a specialist

  • Allergy serum
  • Allergy injections
Nothing

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All charges
Benefit Description : Treatment therapiesHDHP (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 109.

  • Respiratory and inhalation therapy
  • Cardiac rehabilitation following qualifying event/condition is provided for up to 12 weeks for Phase II and Phase III combined
  • Dialysis – hemodialysis and peritoneal dialysis
  • Growth hormone therapy (GHT)
  • Intravenous (IV) Infusion Therapy in a doctor’s office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services.)

Note: When provided in a physician’s office or in an urgent care center, the services listed above do not include the cost of injectable, implantable and IV drugs; see below for the cost of the drugs.

Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that be determine are medically necessary.  See Section 3. How you get care - Other services.

Note: We cover home IV infusion and antibiotic therapy administered by a home health agency under the Home health services benefit.

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

$20 per office visit to a primary care physician

$30 per office visit to a specialist

$500 per visit in a surgical center, hospital, or other facility

Benefit Description : Physical, speech, and occupational habilitative and rehabilitative therapies HDHP (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: We cover physical and occupational therapy under the Home health services benefit when provided by a home health agency as part of an authorized home treatment plan

$30 per office visit

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

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

$20 per office visit

  • Outpatient cardiac rehabilitation following a qualifying event/condition is provided at a Plan facility for up to 12 weeks for Phase II and Phase III combined
$30 per office visit

Not covered:

  • Long-term habilitative and rehabilitative therapy
  • Therapy that we determine will not significantly improve your condition
  • Exercise programs
All charges
Benefit Description : Speech therapy HDHP (You pay After the calendar year deductible… )

60 visits per person per calendar year

Note: We cover speech therapy under the Home health services benefit when provided by a home health agency as part of an authorized home treatment plan.

$30 per office visit

Not covered:

  • Speech therapy for psychosocial and/or developmental delays, such as but not limited to, childhood stuttering
All charges
Benefit Description : Hearing services (testing, treatment, and supplies)HDHP (You pay After the calendar year deductible… )
  • For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

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

$20 per office visit to a primary care physician

$30 per office visit to a specialist

  • External hearing aids
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices

Not covered:

  • Hearing services that are not shown as covered
All charges
Benefit Description : Vision services (testing, treatment, and supplies)HDHP (You pay After the calendar year deductible… )
  • Corrective eyeglasses and frames or contact lenses (hard or soft) for adults age 19 and older per 24-month period.
All charges over $100
  • Corrective eyeglasses and frames or contact lenses (hard or soft) for children through age 18 per 24-month period.*

*Note: You must pay for charges above the $100 allowance and submit a claim form for reimbursement of the 10%.

90% of charges after $100
  • One routine eye exam (including refraction) every 12 month period

Note: See Preventive care, adults and children for eye exams

Nothing
  • Treatment of eye diseases and injury
$30 per office visit

Not covered:

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

$20 per office visit to a primary care physician

$30 per office visit to a specialist

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
  • Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
  • Foot Orthotics
  • Podiatric shoe inserts
All charges
Benefit Description : Orthopedic and prosthetic devices HDHP (You pay After the calendar year deductible… )

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

  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

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

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

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical and anesthesia services. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

50% of Plan Allowance
  • Hair prosthesis prescribed by a physician for hair loss resulting from radiation therapy, chemotherapy or certain other injuries, diseases, or treatment of a disease.
Nothing up to Plan lifetime maximum of $500

Not covered:

  • Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
  • Lumbosacral supports
  • Corsets, trusses, elastic stockings, support hose, and other supportive devices
  • Replacement of prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s physical condition
  • All charges over $500 for hair prosthesis
All charges
Benefit Description : Durable medical equipment (DME)HDHP (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 800-537-9384 for a complete list of covered DME.  Some covered items include:

  • Oxygen systems and oxygen tanks
  • Dialysis equipment
  • Hospital beds (Clinitron and electric beds must be authorized)
  • Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
  • Crutches
  • Walkers
  • Speech generating devices
  • Blood glucose monitors
  • Audible prescription reading devices
  • Insulin pumps
  • C-Pap machine

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

50% of Plan Allowance
  • Oxygen concentrators; and
  • Medically necessary accessories and supplies such as hoses, tubes, oxygen and ostomy supplies
10% of Plan Allowance

Not covered:

  • Durable medical equipment, corrective appliances, prostheses and artificial aids, including supplies and accessories, are excluded when primarily used for convenience, comfort, or in the absence of an illness or injury. Routine periodic servicing, such as cleaning and regulating is not covered.
  • Replacement of durable medical equipment, prosthetic devices and corrective appliances unless it is needed because the existing device has become inoperable through normal wear and tear and cannot be repaired, or because of a change in the member’s condition.
  • Bathroom equipment such as bathtub seats, benches, rails and lifts
  • Home modifications such as stair glides, elevators and wheelchair ramps
  • Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities
All charges
Benefit Description : Home health servicesHDHP (You pay After the calendar year deductible… )
  • Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide. Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less.  The plan will allow up to 60 visits per member per calendar year.  Your Plan Physician will periodically review the program for continuing appropriateness and need.
  • Services include oxygen therapy

$20 per visit

Intravenous (IV) Infusion Therapy and medications

$30 per visit

Not covered:

  • Nursing care requested by, or for the convenience of, the patient or the patient’s family
  • Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication
  • Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
  • Services provided by a family member or resident in the members home
  • Services rendered at any site other than the member’s home
  • Services rendered when the member is not homebound because of illness or injury
  • Private duty nursing services
  • Transportation
All charges
Benefit Description : Chiropractic HDHP (You pay After the calendar year deductible… )

Coverage is limited to 20 visits per calendar year. Services include:

  • Manipulation of the spine and extremities
  • Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
$30 per office visit to a specialist

Not covered:

Any services not listed above

All charges
Benefit Description : Alternative treatmentsHDHP (You pay After the calendar year deductible… )

Biofeedback therapy for the treatment of certain conditions

  • Anesthesia
  • Pain Relief

$20 per office visit to a primary care physician

$30 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

  • Acupuncture
  • Applied kinesiology
  • Aromatherapy
  • Craniosacral therapy
  • Hair analysis
  • Acupressure
  • Naturopathic or homeopathic services
  • Massage therapy
  • Hypnotherapy
  • Reflexology
All charges
Benefit Description : Educational classes and programsHDHP (You pay After the calendar year deductible… )

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

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

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

Nothing (no deductible) 

Coverage is provided for:

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

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

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

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




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care. It is your responsibility to verify that your physician has scheduled your surgery in a Plan facility. We will not pay for services provided by a non-Plan provider or facility without our prior authorization.
  • The deductible is $1,400 for Self Only enrollment, $2,800 per Self Plus One enrollment, or $2,800 for a Self and Family enrollment each calendar year. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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.
  • After you have satisfied your deductible, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses.
  • 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.).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which services require prior authorization and identify which surgeries require prior authorization.



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

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Removal of tumors and cysts
  • Normal pre- and post-operative care by the surgeon
  • Endoscopy procedures
  • Biopsy procedures
  • Voluntary sterilization for men (e.g., vasectomy)
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Treatment of burns
  • Routine circumcision of a newborn
  • Insertion of internal prosthetic devices. See Section 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.

$20 per office visit to a primary care physician

$30 per office visit to a specialist

See section 5(c) for facility charges.

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

Nothing (no deductible)

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.

$20 per office visit to a primary care physician

$30 per office visit to a specialist

See section 5(c) for facility charges.

  • 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 page 24. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

$20 per office visit to a primary care physician

$30 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

  • Reversal of voluntary surgically-induced sterilization
  • Surgery primarily for cosmetic purposes
  • Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
  • Routine treatment of conditions of the foot (see Foot care)
All charges
Benefit Description : Reconstructive surgery HDHP (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 anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
  • 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 lymphedemas
    • breast prostheses and surgical bras (See Orthopedic and prosthetic devices in Section 5(a))

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.

$20 per office visit to a primary care physician

$30 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
All charges
Benefit Description : Oral and maxillofacial surgery HDHP (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
  • Surgical correction of cleft lip, cleft palate or severe functional malocclusion
  • Removal of stones from salivary ducts
  • Excision of leukoplakia or malignancies
  • Medically necessary surgical treatment of TMJ (must be preauthorized)
  • Excision of cysts and incision of abscesses when done as independent procedures
  • Other surgical procedures that do not involve the teeth or their supporting structures
  • Removal of bony impacted wisdom teeth

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

$20 per office visit to a primary care physician

$30 per office visit to a specialist

See section 5(c) for facility charges.

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges
Benefit Description : Organ/tissue transplantsHDHP (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 page 24.

  • 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)

$30 per specialist visit

See section 5(c) for facility charges.

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

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

$30 per specialist visit

See section 5(c) for facility charges.

Blood or marrow stem cell transplants

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

The Plan extends coverage for the diagnoses as indicated below.

  • Allogeneic transplants for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin's lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced neuroblastoma
    • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • 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 nonlymphocytic (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.

$30 per specialist visit

See section 5(c) for facility charges.

Mini-transplants performed in a clinical trial setting (non-myeloblative, 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 nonlymphocytic (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 PHN, 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

$30 per specialist visit

See section 5(c) for facility charges.

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 lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Colon cancer
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Myeloproliferative disorders (MDDs)
    • Myelodysplasia/Myelodysplastic Syndromes
    • 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's lymphoma
    • 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

$30 per specialist visit

See section 5(c) for facility charges.

National Transplant Program (NTP) - Transplants which are non-experimental or non-investigational are a covered benefit.  Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery.  The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures.  A transplant is non-experimental and non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate for 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 not be covered.

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

$30 per specialist visit

See section 5(c) for facility charges.

Clinical trials must meet the following criteria:

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

B. All of the following criteria must be met:

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

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

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

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

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

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

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

4. The member must:

a. Not be treated “off protocol,” and

b. Must actually be enrolled in the trial.

$30 per specialist visit

See section 5(c) for facility charges.

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Transplants not listed as covered
  • Travel expenses, lodging, and meals
All charges
Benefit Description : Anesthesia HDHP (You pay After the calendar year deductible… )

Professional services provided in –

  • Hospital (inpatient)
  • Hospital outpatient department
  • Skilled nursing facility
  • Ambulatory surgical center
10% of Plan Allowance

Professional services provided in –

  • Office

$20 per office visit to a primary care physician

$30 per office visit to a specialist




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

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions , limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
  • The deductible is $1,400 for Self Only enrollment, $2,800 per Self Plus One enrollment, or $2,800 for a Self and Family enrollment each calendar year. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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.
  • 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.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.
  • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.



Benefit Description : Inpatient hospitalHDHP (You Pay After the calendar year deductible...)

Room and board, such as

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

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

10% of Plan Allowance

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
  • Take-home items
  • Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
10% of Plan Allowance

Not covered:

  • Custodial care
  • Non-covered facilities, such as nursing homes, long-term care facilities, and schools, rest cures, domiciliary or convalescent cares 
  • Whole blood and concentrated blood cells not replaced by the member
  • Personal comfort items, such as phone, television, barber services, guest meals and beds
  • Private nursing care
All charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHDHP (You Pay After the calendar year deductible...)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and X-rays
  • Administration of blood, blood plasma, and other biologicals
  • Blood products, derivatives and components, artificial blood products and biological serum
  • Pre-surgical testing
  • Dressings, casts, and sterile tray services
  • Medical supplies, including oxygen
  • Anesthetics and anesthesia service

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

$500 per visit

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

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

*See below for exceptions

$30 per specialist visit

Complex diagnostic tests limited to:

  • CT scans, MRIs, MRAs, and electron beam scans
  • PET and SPECT scans
  • Angiography, and other procedures that require vascular catheterization and/or the injection of medication, imaging contrast, or other substance
  • Any radiological procedure that must be performed in conjunction with a diagnostic surgical procedure (for example: ultrasonic guidance procedures)
  • Diagnostic nuclear medicine, including provision of radiopharmaceuticals for diagnostic purposes
  • Genetic testing—diagnostic*

*Note:  These services need precertification.  See “Services requiring prior approval” on page 24.

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

$175 copay

Not covered:

  • Personal comfort items
  • Whole blood and concentrated red blood cells not replaced by the member
All charges
Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHDHP (You Pay After the calendar year deductible...)

Extended care benefit:  All necessary services during confinement in a skilled nursing facility with a 30 day per member per calendar year limit when full-time nursing care is necessary and the confinement is medically appropriate as determined by a Plan doctor and approved by the Plan.

10% of Plan Allowance

Not covered:

  • Custodial care, personal, comfort or convenience items
All charges
Benefit Description : Hospice careHDHP (You Pay After the calendar year deductible...)
  • Services for pain and symptom management
  • Short-term inpatient care and procedures necessary for pain control
  • Respite care may be provided only on an occasional basis and may not be provided longer than five (5) days
  • Home visits made by a physician, nurse, home health aide, social worker or therapist with no limit on number of visits
  • General medical equipment and supplies related to the terminal illness

$10 copay

Not covered:

  • Independent nursing
  • Homemaker services
  • Specialized, customized equipment
All charges
Benefit Description : AmbulanceHDHP (You Pay After the calendar year deductible...)

The plan 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

To transport a member from home to hospital for medically necessary inpatients treatment when an ambulance is required to safely and adequately transport the member

10% of Plan Allowance

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 require prior approval from the Plan

All charges



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

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 $1,400 for Self Only enrollment, $2,800 per Self Plus One enrollment, or $2,800 for a Self and Family enrollment each calendar year. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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.
  • After you have satisfied your deductible, you will be responsible for your coinsurance amounts and copayments for eligible medical expenses.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.



What is a medical emergency?

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


What to do in case of emergency:

  • Emergencies within our service area:

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person’s health or with respect to a pregnant woman, the health of the woman and her unborn child.

Whether you are in or out of an Altius HMO service area, we simply ask that you follow the guidelines below when you believe you need emergency care.

  • Call the local emergency hotline (e.g. 911) or go to the nearest emergency facility. For non-emergency services, care may be obtained from a retail clinic, a walk-in clinic, an urgent care center or by calling Teladoc. If a delay would not be detrimental to your health, call your primary care physician. Notify your primary care physician as soon as possible after receiving treatment.
  • After assessing and stabilizing your condition, the emergency facility should contact your primary care physician so he/she can assist the treating physician by supplying information about your medical history.
  • If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Altius as soon as possible.
  • Emergencies outside our service area:

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

If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or emergency problem does not qualify for coverage, it may be necessary to provide us with additional information. We will send you an Emergency Room Notification Report to complete, or a Member Services representative can take this information by phone.




Benefit Description : Emergency within our service areaHDHP (You pay after deductible )
  • Emergency or urgent care at a doctor’s office

$20 per PCP visit

$30 per specialist visit

  • Emergency or urgent care at an urgent care center
$30 copayment per urgent care center visit
  • Emergency care as an outpatient at a hospital, (Emergency Room) including doctors’ services

Note: Inpatient facility benefits apply if you are admitted to the hospital; see Inpatient hospital in Section 5(c).

$200 copayment per visit

Not covered:

  • Elective care or non-emergency care in a hospital emergency room
  • Follow-up care in a hospital emergency room, unless we have given prior authorization
All charges
Benefit Description : Emergency outside our service areaHDHP (You pay after deductible )
  • Emergency or urgent care at a doctor’s office

$20 per PCP visit

$30 per specialist visit

  • Emergency or urgent care at an urgent care center
$30 copayment per urgent care center visit
  • Emergency care as an outpatient at a hospital, (Emergency Room) including doctors’ services

Note: Inpatient facility benefits apply if you are admitted to the hospital; see Inpatient hospital in Section 5(c).

$200 copayment per visit

Not covered:

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

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.

$30 per consult
Benefit Description : AmbulanceHDHP (You pay after deductible )
Altius 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

    10% of Plan Allowance

    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 (HDHP)

    Important things you should keep in mind about these benefits:

    • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
    • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
    • YOU MUST GET PREAUTHORIZATION FOR CERTAIN SERVICES. Benefits are payable only when we determine the care is clinically appropriate to treat your condition. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan. Please see Section 3 of this brochure for a list of services that require preauthorization.
    • The deductible is $1,400 for Self Only enrollment, $2,800 per Self Plus One enrollment, or $2,800 for a Self and Family enrollment each calendar year. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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.
    • The Plan can assist you in locating participating providers, 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 behavioral health care services that are covered under your specific plan by calling Member Services at 800-537-9384.  A referral from your PCP is not necessary to access behavioral health care but your PCP may assist in coordinating your care.
    • We will provide medical review criteria or reasons for treatment plan 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 medically necessary treatment plan in favor of another.



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

    We cover professional services by licensed professional mental health and substance use 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
    $20 per office visit
    • Telemedicine Behavioral Health consult

    $20 per office visit

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

    $20 per office visit

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

    The plan covers medically necessary applied behavior analysis (ABA) therapy when provided by network behavioral health providers. These providers include:

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

    Note: Requires Precertification. See “Services requiring our prior approval” on page 24. You are responsible for ensuring that we are asked to precertify your care.  You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

    $20 per visit
    Benefit Description : DiagnosticHDHP (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
    $20 per office visit
    Benefit Description : Inpatient hospital or other covered facilityHDHP (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
    10% of Plan Allowance
    Benefit Description : Outpatient hospital or other covered facility HDHP (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)
    $20 per office visit
    Benefit Description : Not CoveredHDHP (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 (HDHP)

    Important things you should keep in mind about these benefits:

    • This is a five tier open formulary pharmacy plan, Advanced Control Formulary. The formulary is a list of drugs that your health plan covers. With your Advanced Control Formulary Pharmacy plan, each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Each tier has a separate out-of-pocket cost.
      • Preferred generic
      • Preferred brand
      • Non-preferred generic and brand
      • Preferred specialty
      • Non-preferred specialty
    • We cover prescribed drugs and medications, as described in the chart beginning on the next page.
    • The deductible is $1,400 for Self Only enrollment, $2,800 per Self Plus One enrollment, or $2,800 for a Self and Family enrollment each calendar year. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment they will then be covered under Plan 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.
    • 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/authorization for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
    • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
    • Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. Upon approval by the Plan, the prescription is covered for the current calendar year or a specified time period, whichever is less.



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

    • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice. 
    • Where you can obtain them. You may fill non-emergency prescriptions at a participating Plan retail pharmacy or by mail order for 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, and for a 31-day up to a 90-day supply of medication for two (2) copays. In no event will the copay exceed the cost of the prescription drug. Please call Member Services at 800-537-9384 for more details on how to use the mail order program. Mail order is not available for drugs and medications ordered through a network Specialty Pharmacy. Prescriptions ordered through a network Specialty Pharmacy are only filled for up to a 30-day supply due to the nature of these prescriptions. In an emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. For retail pharmacy transactions, you must present your Member ID card at the point of sale for coverage. If you obtain an emergency prescription at a pharmacy that does not participate with the plan, you will need to pay the pharmacy the full price of the prescription and submit a claim for reimbursement subject to the terms and conditions of the plan. 
    • We use a formulary. The formulary is a list of drugs that your Plan covers. Drugs are prescribed by Plan doctors and dispensed in accordance with the 2021 Pharmacy Drug (Formulary) Guide. Certain drugs require your doctor to get precertification or step therapy from the Plan before they can be covered under the Plan. Your prescription drug plan includes drugs listed in the 2021 Pharmacy Drug (Formulary) Guide. Prescription drugs listed on the Formulary Exclusions List are excluded unless a medical exception is approved by the Plan. If it is medically necessary for you to use a prescription drug on the formulary exclusions list, you or your prescriber must request a medical exception. Visit our website at www.aetnafeds.com to review our 2021 Pharmacy Drug (Formulary) Guide or call 800-537-9384.
    • Drugs not on the formulary. Formularies are developed and reviewed by the CVS Caremark Pharmacy and Therapeutics Committee, comprised of physicians, pharmacists and other clinicians that review drugs for inclusion in the formulary. They consider the drug’s effectiveness and safety in their evaluation. While most of the drugs on the non-formulary list are brand drugs, some generic drugs also may be on the non-formulary list. For example, this may happen when brand medications lose their patent and the FDA has granted a period of exclusivity to specific generic manufacturers. When this occurs, the price of the generic drug may not decrease as you might think most generic drugs do. This period of exclusivity usually ranges between 3-6 months. Once this time period expires, competition from other generic manufacturers will generally occur and this helps lower the price of the drug and this may lead the Plan to re-evaluate the generic for possible inclusion on the formulary. We will place some of these generic drugs that are granted a period of exclusivity on our non-formulary list, which requires the highest copay level. Remember, a generic equivalent will be dispensed, if available, unless your physician specifically requires a brand name and writes "Dispense as Written" (DAW) on the prescription, so discuss this with your doctor.
    • Choose generics. The Plan requires the use of generics if a generic drug is available. If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance* unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained from the Plan. Generics contain the same active ingredients in the same amounts as their brand name counterparts and have been approved by the FDA. By using generic drugs, you will see cost savings, without jeopardizing clinical outcome or compromising quality. * The differential/penalty will not apply to plan accumulators (example: 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.
    • These are the dispensing limitations. Prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy or by mail order may be dispensed for 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, and a 31-day up to a 90-day supply of medication for two copays. In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name.

      In the event that a member is called to active military duty and requires coverage under their prescription plan benefits of an additional filing of their medication(s) prior to departure, their pharmacist will need to contact the plan. Coverage of additional prescriptions will only be allowed if there are refills remaining on the member's current prescription or a new prescription has been issued by their physician. The member is responsible for the applicable copayment for the additional prescription.
    • The Plan allows coverage of a medication refill when at least 80% of the previous prescription, according to the physician’s prescribed directions, has been utilized. For a 30-day supply of medication, this provision would allow a prescription refill to be covered 24 days after the last filling, thereby allowing a member to have an additional supply of their medication, in case of emergency.
    • When you do have to file a claim. Send your itemized bill(s) to: Aetna, Pharmacy Management, P.O. Box 52444, Phoenix, AZ 85072-2444.

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

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

      Certain Specialty Formulary medications identified on the Specialty Drug List next to the drug name 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 visit copay. If you obtain the prescribed medications directly from a network specialty pharmacy, you will pay the applicable copay as outlined in Section 5(f) of this brochure.

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



    Benefit Description : Covered medications and suppliesHDHP (You pay After the calendar year deductible... )

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

    • Drugs approved by the U.S. Food and Drug Administration for which a prescription is required by Federal law, except those listed as Not covered
    • Insulin
    • Disposable needles and syringes needed to inject covered prescribed medications
    • Diabetic supplies limited to:
      • Lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips
    • 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 or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

    $7 per covered generic formulary drug;

    $25 per covered brand name formulary drug;

    $50 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:

    $21 per covered generic formulary drug;

    $75 per covered brand name formulary drug;

    $150 per covered non-formulary (generic or brand name) drug.

    Women's contraceptive drugs and devices

    • Generic oral contraceptives on our formulary list
    • Generic emergency contraception, including 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

    Nothing (no deductible) 

    • 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 or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

    $25 per covered brand name formulary drug;

    $50 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:

    $75 per covered brand name formulary drug;

    $150 per covered non-formulary (generic or brand name) drug.

    Specialty Medications

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

    Certain Specialty Formulary medications identified on the Specialty Drug List may be covered under the medical or pharmacy section of this brochure. Please refer to page 128, Specialty Drugs for more information or visit: www.aetnafeds.com/pharmacy.

    Preferred:

    20% of Plan Allowance

    Non-preferred (non- formulary):

    35% of Plan Allowance

    (not available through mail order)

    Limited benefits:

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

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

    $7 per covered generic formulary drug;

    $25 per covered brand name formulary drug;

    $50  per covered non-formulary (generic or brand name) drug.

    Benefit Description : Preventive care medicationsHDHP (You pay After the calendar year deductible... )

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

    Drugs and supplements are covered without cost-share which includes some over-the-counter, 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 formulary guide for a complete list of preventive drugs including coverage details and limitations: www.aetnafeds.com/pharmacy

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

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

    Nothing (no deductible)

    Not covered:

    • Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law or covered by the plan.
    • Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
    • Vitamins, unless otherwise stated (including prescription vitamins), nutritional supplements not listed as a covered benefit, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition except for nutritional formulas for the treatment of phenylketonuria branched chain ketonuria, galactosemia and homocystinuria when administered under the direction of a Plan doctor (please see Durable Medical Equipment section on page 103).
    • Medical supplies such as dressings and antiseptics
    • Lost, stolen or damaged drugs
    • Drugs for cosmetic purposes
    • Fertility drugs
    • Drugs to enhance athletic performance
    • Drugs used for the purpose of weight reduction (i.e., appetite suppressants)
    • Prophylactic drugs including, but not limited to, anti-malarials for travel
    • Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
    • Compounded thyroid hormone therapy

    Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See page 105).  OTC drugs will not be covered unless you have a prescription and that prescription is presented at the pharmacy and processed through our pharmacy claim system.

    All charges



    Section 5(g). Dental Benefits (HDHP)

    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 Program (FEDVIP) Dental Plan, your FEHB Plan will be your 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.
    • Plan dentists must provide or arrange your care. You are responsible for ensuring that your provider is a Plan provider.
    • The deductible is $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 a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan 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.
    • After you have satisfied your deductible, you will be responsible for your coinsurance amounts and copayments for eligible medical expenses.
    • 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. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
    • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



    Dental benefits : Accidental injury benefitHDHP (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.

    $20 per office visit to a primary care physician

    $30 per office visit to a specialist

    See section 5(c) for facility charges.

    Not covered:

    • Implants
    All charges
    Dental benefits : Dental benefitsHDHP (You Pay After the calendar year deductible... )
    We have no other dental benefits.

    N/A




    Section 5(h). Wellness and Other Special Features

    TermDefinition

    Completing Health Risk Assessments

    The Plan will provide a health risk assessment and online digital coaching.

    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 the Aetna Member Website from www.aetnafeds.com to register and access a secure, personalized view of your benefits.

    With Aetna Member Website, you can:

    • 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 Member Website 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

    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.

    Services for the deaf and hearing impaired800-628-3323

    National Medical Excellence Program

    National Medical Excellence Program helps eligible members access appropriate, covered treatment for solid organ and tissue transplants using our Institutes of Excellence™ network. We coordinate specialized treatment needed by members with certain rare or complicated conditions and assist members who are admitted to a hospital for emergency medical care when they are traveling temporarily outside of the United States. Services under this program must be preauthorized. Contact member services at 800-537-9384 for more information.




    Section 5(i). Health Education Resources and Account Management Tools

    TermDefinition

    Health education resources

    We keep you informed on a variety of issues related to your good health. Visit our website at www.aetnafeds.com or call Member Services at 800-537-9384 for information on:

    • Aetna Member Website
    • Healthwise® Knowledge base
    • Informed Health® Line
    • Hospital comparison tool and Estimate the Cost of Care tool
    • Medical Procedure and Price-a-Dental Procedure tools
    • Online provider directory
    • Cost of care tools

    Account management tools

    For each HSA and HRA account holder, we maintain a complete claims payment history online through the Aetna Member Website. You can access the Aetna Member Website at www.aetnafeds.com.

    • Your balance will also be shown on your explanation of benefits (EOB) form.
    • You will receive an EOB after every claim.

    Consumer choice information

    Care support

    Patient safety information is available online at www.aetnafeds.com




    Non-FEHB Benefits Available to Plan Members

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

    Vision Discounts

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

    Hearing Discounts

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

    Healthy lifestyle discounts

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

    Natural products and services discount

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

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

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

    Discount offers may be available but are not guaranteed under our contract with the FEHB program. Please see 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:

    • All services from a non-Plan provider, including hospitals, surgical centers, and other facilities (except emergency care and out-of-area urgent care) that we have not approved (see Section 3).
    • Services, drugs, or supplies you receive while you are not enrolled in this Plan
    • Services, drugs, or supplies that are 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, and 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 or supplies given by a health care provider who lives in the same household as the patient
    • 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.
    • Items and services provided by clinical trial sponsor without charge.
    • Care for conditions that state or local law requires to be treated in a public facility, including but not limited to, mental illness commitments.
    • Court ordered services, or those required by court order as a condition of parole or probation, except when medically necessary.
    • Educational services for treatment of behavioral disorders.
    • Services provided by a family member or resident in the member’s home.
    • Services or supplies we are prohibited from covering under the Federal law.



    Section 7. Filing a Claim for Covered Services

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

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

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




    TermDefinition

    Medical, hospital and prescription drug benefits

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

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

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

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

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

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

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

    Deadline for filing your claim

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

    Post-service claims procedures

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

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

    If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.
    Authorized RepresentativeYou may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a health care professional with knowledge of your medical condition 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 800-537-9384. 

    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.

    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 decision will not afford deference to the initial decision and will be conducted by a plan representative who is neither the individual who made the initial decision that is the subject of the reconsideration, nor the subordinate of that individual.

    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 or HDHP fiduciary regarding the administration of an HSA or 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, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512 or calling 800-537-9384; 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 (optional for member), if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide our decision more quickly.

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

     

     

    2

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

    a) Pay the claim or

    b) Write to you and maintain our denial or

    c) Ask you or your provider for more information

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

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

    3

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

    You must write to OPM within:

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

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

    Send OPM the following information:

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

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

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

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

    4

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

    If you do not agree with OPM’s decision, your only recourse is to 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 800-537-9384.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.

    Please remember that we do not  make decisions about plan eligibility issues.  For example, we do not determine whether you or a dependent is covered under this plan.  You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Worker’s Compensation Programs if you are receiving Worker’s 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.pdfWhen we are the primary payor, we will 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. You must use our providers.

    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.

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

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

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

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

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

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

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

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

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

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

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

    Clinical Trials

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

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

    • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this plan.
    • 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. 
    • 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.

    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 by your Plan provider, or prior authorized by us as required.

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

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

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

    We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:

    • Medical services and supplies provided by physicians and other health care professionals.

    Please review the following table. It illustrates your cost share if you are enrolled in Medicare Parts A and B. Medicare will be primary for all Medicare eligible services. Members must use providers who accept Medicare’s assignment. 

    Benefit Description: Deductible
    High Option You Pay Without Medicare: $50 Self Only/$100 Self Plus One and Self and Family
    High Option You Pay With Medicare Parts A & B (primary): $0 Self Only/$0 Self Plus One and Self and Family

    Benefit Description: Part B Premium Reimbursement Offered
    High Option You Pay Without Medicare: N/A
    High Option You Pay With Medicare Parts A & B (primary): No reimbursement

    Benefit Description: Primary Care Physician
    High Option You Pay Without Medicare: $25 per visit
    High Option You Pay With Medicare Parts A & B (primary):$0 per visit

    Benefit Description: Specialist
    High Option You Pay Without Medicare: $40 per visit
    High Option You Pay With Medicare Parts A & B (primary): $0 per visit

    Benefit Description: Inpatient Hospital
    High Option You Pay Without Medicare: $200 per day up to $1,000 per admission
    High Option You Pay With Medicare Parts A & B (primary): $0 per visit

    Benefit Description: Outpatient Hospital
    High Option You Pay Without Medicare: $400 copay
    High Option You Pay With Medicare Parts A & B (primary): $0 per visit

    Benefit Description: Incentives Offered
    High Option You Pay Without Medicare: N/A
    High Option You Pay With Medicare Parts A & B (primary): We offer no additional incentives when a member enrolls in Medicare Part B

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

    Tell us about your Medicare coverage

    You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask.  You must also tell us about the 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. Please call us at 888-788-0390.  We do not waive cost-sharing for your FEHB coverage.

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

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

    Medicare prescription drug coverage (Part D)

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




    Primary Payer Chart

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


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


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

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




    Section 10. Definitions of Terms We Use in This Brochure

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

    Clinical Trials Cost Categories

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

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

    • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this Plan.
    • 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.
    • 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.

    Coinsurance

    See Section 4, page 29.

    Copayment

    See Section 4, page 29.

    Cost-sharing

    See Section 4, page 29.

    Covered services Care we provide benefits for, as described in this brochure.
    Custodial careAny 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 29.

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

    Experimental or investigational service

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

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

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

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

    Medical necessity

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

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

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

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

    Open Access HMOYou can go directly to any network specialist for covered services without a referral from your primary care physician. Whether your covered services are provided by your selected primary care physician (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.
    Plan allowance

    Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows:

    We may take into account factors such as the complexity, degree of skill needed, type or specialty of the provider, range of services provided by a facility, and the prevailing charge in other areas in determining the Plan allowance for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of providers in the area.

    Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
    Pre-service claimsThose claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
    Precertification

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

    Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services.

    Preventive careHealth 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 if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
    Respite careCare furnished during a period of time when your family or usual caretaker cannot, or will not, attend to your needs.  Respite care is not covered. 
    SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

    Urgent care and urgent care claims

    Covered benefits required in order to prevent serious deterioration of your health that results from 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. 

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

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

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

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

    Us/WeUs and We refer to Altius Health Plans. (Note: This plan is a part of Aetna Inc., as noted throughout the brochure, correspondence should be sent to Aetna accordingly.)
    You You refers to the enrollee and each covered family member.



    High Deductible Health Plan (HDHP) Definitions

    TermDefinition

    Deductible

    A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for those services. See page 29.

    Health Reimbursement Arrangement (HRA)

    A health reimbursement arrangement (HRA) is an employer-funded account that is set up to reimburse qualified medical expenses incurred by you and your dependents (including your spouse) who are enrolled in your employer-sponsored plan, up to a maximum dollar amount for a coverage period. The HRA is not portable if you leave the Federal government or switch to another plan. See the chart beginning on page 82.

    Health Savings Account (HSA)

    A health savings account (HSA) is a trust or custodial account that is set up with a qualified trustee to pay or reimburse certain medical expenses incurred by you, your spouse, and dependents you may claim for tax purposes (even if they are not enrolled in your health plan). You must be enrolled in a high deductible health plan (HDHP) and meet certain other eligibility requirements to qualify for an HSA. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan. See the chart beginning on page 82.




    Index (Altius)

    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
    Alternative treatments
    Ambulance
    Anesthesia
    Autologous bone marrow transplant
    Biopsy
    Blood plasma
    Casts
    Catastrophic protection
    Changes for 2021
    Chemotherapy
    Chiropractic
    Cholesterol
    Claims
    Coinsurance
    Colorectal cancer screening
    Congenital anomalies
    Cost-Sharing
    Covered charges
    Deductible
    Definitions
    Dental care
    Diagnostic services
    Disputed claims
    Dressings
    Durable medical equipment
    Effective date of enrollment
    Emergency
    Experimental or investigational
    Eyeglasses
    Family planning
    Fecal occult blood test
    Fraud
    General exclusions
    Home health services
    Hospital
    Immunizations
    Infertility
    Inpatient hospital
    Insulin
    Mammogram
    Maternity benefits
    Medicaid
    Medically necessary
    Medicare
    Original
    Members
    MRI
    Newborn
    Non-FEHB benefits
    Nurse
    Registered Nurse
    Occupational therapy
    Office visits
    Oral and maxillofacial
    Out-of-pocket expenses
    Oxygen
    Pap test
    Physician
    Precertification
    Prescription drugs
    Preventive care, adult
    Preventive care, children
    Preventive services
    Prior approval
    Prosthetic devices
    Psychologist
    Radiation therapy
    Room and board
    Skilled nursing facility
    Smoking cessation
    Social worker
    Speech therapy
    Splints
    Subrogation
    Substance misuse
    Surgery
    Anesthesia
    Oral
    Outpatient
    Reconstructive
    Syringes
    Temporary Continuation of Coverage (TCC)
    Transplants
    Treatment therapies
    Vision care
    Vision services
    Wheelchairs
    Workers' compensation
    X-rays



    Notes










    Summary of Benefits for the High Option of Altius Health Plans - 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.
    • We only cover services provided or arranged by Plan physicians, except in emergencies.



    TermDefinition 1Definition 2

    Medical preventive care (specified services only)

    Nothing

    35

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

    Office visit copay: $25 primary care; $40 specialist

    34

    Medical services provided by physicians: Teladoc

    $30 per consult

    34

    Services provided by a hospital: Inpatient

    $200 per day up to $1,000 per admission copay

    57

    Services provided by a hospital: Outpatient

    $400 per visit

    58

    Emergency benefits: In-area

    $250 for emergency room services

    62

    Emergency benefits: Out-of-area

    $250 for emergency room services

    62

    Mental health and substance use disorder treatment:

    Regular cost-sharing

    64

    Prescription drugs: Retail pharmacy

    30-day supply – $7 preferred generic; $40 preferred brand name; 40% coinsurance up to $240 maximum for non-preferred (non-formulary)

    69

    Prescription drugs: Mail order

    90-day supply – $7 preferred generic; $80 preferred brand name; 40% coinsurance up to $720 maximum for non-preferred (non-formulary)

    69

    Prescription drugs: Specialty drugs

    30% preferred; 50% non-preferred

    70

    Dental care:

    See schedule of Dental Benefits

    73

    Vision care:

    Annual eye examinations and refractions - Nothing

    41

    Special features:

    Flexible benefits option; services for deaf and hearing impaired and National Medical Excellence Program

    133

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

    Nothing after $5,500/individual or $11,000/ for Self Plus One or Self and Family enrollment per year. Some costs do not count toward this protection

    30




    Summary of Benefits for the Standard Option of Altius Health Plans - 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.
    • We only cover services provided or arranged by Plan physicians, except in emergencies.



    TermDefinition 1Definition 2

    Medical preventive care (specified services only)

    Nothing

    35

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

    Office visit copay: $25 primary care; $45 specialist

    34

    • Teladoc

    $40 per consult

    34

    Services provided by a hospital: Outpatient

    $650 per visit

    58

    Services provided by a hospital: Inpatient

    15% coinsurance

    57

    Emergency benefits: Out-of-area

    $250 for emergency room services

    62

    Emergency benefits: In-area

    $250 for emergency room services

    62

    Mental health and substance use disorder treatment:

    Regular cost-sharing

    64

    Prescription drugs: Specialty drugs

    30% preferred; 50% non-preferred

    70

    Prescription drugs: Mail order

    31-90-day supply - $7 preferred generic; $100 preferred brand name; 50% coinsurance up to $720 maximum non-preferred (non-formulary)

    69

    Prescription drugs: Retail pharmacy

    30-day supply - $7 preferred generic; $50 preferred brand name; 50% coinsurance up to $240 maximum non-preferred (non-formulary)

    69

    Dental care:

    Accidental Dental Only

    73

    Vision care:

    Annual eye examinations and refractions - Nothing

    41

    Special features:

    Flexible benefits option; services for deaf and hearing impaired and National Medical Excellence Program

    133

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

    Nothing after $6,000/individual or $12,000/ for Self Plus One or Self and Family enrollment per year.
    Some costs do not count toward this protection

    30




    Summary of Benefits for the High Deductible Health Plan (HDHP) of Altius Health Plans - 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 at www.aetnafeds.com.
    • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
    • We only cover services provided or arranged by Plan physicians, except in emergencies.
    • All covered services listed below, except specified preventive care services, are subject to the calendar year deductible of $1,400 for Self Only, $2,800 for Self Plus One, and $2,800 for Self and Family. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
    • In 2021, for each month you are eligible for the Health Savings Account (HSA) premium pass through, we will contribute to your HSA $62.50 per month for Self Only enrollment, $125.00 for Self Plus One enrollment or $125.00 per month for Self and Family enrollment. For the HSA, you may use your HSA or pay out-of-pocket to satisfy your calendar year deductible. For the Health Reimbursement Arrangement (HRA), your health charges are applied to your annual HRA Fund of $750 for Self Only, $1,500 for Self Plus One, and $1,500 for Self and Family.



    TermDefinition 1Definition 2

    Medical preventive care (specified services only)

    Nothing (not subject to deductible)

    91

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

    Office visit copay: $20 primary care; $30 specialist

    95

    • Teladoc

    $30 per consult

    95

    Services provided by a hospital: Inpatient

    10%

    115

    Services provided by a hospital: Outpatient

    $500 per visit

    116

    Emergency benefits: In-area

    $200 for emergency room services

    120

    Emergency benefits: Out-of-area

    $200 for emergency room services

    120

    Mental health and substance use disorder treatment:

    Regular cost sharing

    123

    Prescription drugs: Retail pharmacy

    30-day supply – $7 preferred generic; $25 preferred brand name; $50 non-preferred

    NOTE: Deductible does not apply to Preventive Medications

    128

    Prescription drugs: Mail order

    31-90-day supply – $21 preferred generic; $75 preferred brand name; $150 non-preferred

    128

    Prescription drugs: Specialty drugs

    20% preferred; 35% non-preferred

    129

    Dental care:

    Accidental injury benefit only: regular cost sharing. No benefit for routine dental care

    132

    Vision care:

    Annual eye examinations and refractions - Nothing

    101

    Special features:

    Flexible benefits option; services for deaf and hearing impaired and National Medical Excellence Program

    133

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

    Nothing after $6,000/Self Only or $12,000/Self Plus One or Self and Family enrollment per year. Some costs do not count toward this protection

    30




    2021 Rate Information for Altius Health Plans

    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.

     




    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
    Standard Option Self OnlyDK4$241.58$166.01$523.42$359.69$162.65$152.59
    Standard Option Self Plus OneDK6$517.46$373.71$1,121.16$809.71$366.52$344.96
    Standard Option Self and FamilyDK5$562.25$337.84$1,218.21$731.99$330.03$306.61
    Type of EnrollmentEnrollment CodeNon-Postal Premium
    BiWeekly
    Gov't Share
    Non-Postal Premium
    BiWeekly
    Your Share
    Non-Postal Premium
    Monthly
    Gov't Share
    Non-Postal Premium
    Monthly
    Your Share
    Postal Premium
    BiWeekly
    Category 1 Your Share
    Postal Premium
    BiWeekly
    Category 2 Your Share
    High Option Self Only9K1$241.58$242.28$523.42$524.94$238.92$228.86
    High Option Self Plus One9K3$517.46$542.00$1,121.16$1,174.34$534.81$513.25
    High Option Self and Family9K2$562.25$507.81$1,218.21$1,100.25$500.00$476.58
    HDHP Option Self Only9K4$232.79$77.59$504.37$168.12$74.49$64.40
    HDHP Option Self Plus One9K6$476.95$158.98$1,033.39$344.46$152.62$131.96
    HDHP Option Self and Family9K5$486.50$162.16$1,054.07$351.36$155.68$134.60