Although a specific service may be listed as a covered benefit, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition. Refer to the “Key Terms” section for the definition of “medically necessary.”
Certain services must be pre-certified by Aetna. Your participating provider is responsible for obtaining this approval.
Primary and preventive care
One of the Plan’s goals is to help you maintain good health through preventive care. Routine exams, immunizations and well-child care contribute to good health and are covered by the Plan (after any applicable co-payment) if provided by your PCP or on referral from your PCP:
- Office visits with your PCP during office hours and during non-office hours.
- Home visits by your PCP.
- Treatment for illness and injury.
- One routine physical examination per calendar year, as recommended by your PCP.
- Well-child care from birth, including immunizations and booster doses.
- Health education counseling and information.
- Annual prostate screening (PSA) and digital exam for males age 40 and over, and for males considered to be at high risk who are under age 40, as directed by physician.
- Routine gynecological examinations and Pap smears performed by your PCP. You may also visit a participating gynecologist for a routine GYN exam and Pap smear without a referral.
- Routine mammograms for female plan participants age 35 or over.
- Colorectal cancer screening for those age 50 and older and at normal risk for developing colon cancer.
- Bone mass measurement to determine an individual's risk of osteoporosis.
- Routine immunizations (except those required for travel or work).
- Expanded access to eligible immunizations by allowing participants to obtain these through retail pharmacies/pharmacists.
- Periodic routine eye examinations. You may visit a participating provider without a referral as follows:
- age 0-18 years - one exam every calendar year.
- age 19-44 - one exam every 24 months if you wear eyeglasses or contact lenses.
- age 19-44 years - one exam every 36 months if you do not wear eyeglasses or contact lenses.
- age 45 or over - one exam every 24 months.
- Prescription lenses and frames, including contact lenses, subject to any allowances shown in the “Co-payment Schedule.”
- Injections, including routine allergy desensitization injections.
Specialty and outpatient care
The Plan covers the following specialty and outpatient services. You must have a prior written or electronic referral from your PCP in order to receive coverage for any non-emergency services the specialist or facility provides.
- Participating specialist office visits.
- Participating specialist consultations, including second opinions.
- Outpatient surgery for a covered surgical procedure when furnished by a participating outpatient surgery center.
- Preoperative and postoperative care.
- Casts and dressings.
- Radiation therapy.
- Cancer chemotherapy.
- Short-term speech, occupational (except vocational rehabilitation and employment counseling), and physical therapy for treatment of non-chronic conditions and acute illness or injury.
- Cognitive therapy associated with physical rehabilitation for treatment of non-chronic conditions and acute illness or injury.
- Short-term cardiac rehabilitation provided on an outpatient basis following angioplasty, cardiovascular surgery, congestive heart failure or myocardial infarction.
- Short-term pulmonary rehabilitation provided on an outpatient basis for the treatment of reversible pulmonary disease.
- Diagnostic, laboratory and imaging services, including X-rays.
- Emergency care including ambulance service - 24 hours a day, 7 days a week (see “In Case of Emergency”).
- Home health services provided by a participating home health care agency, including:
- skilled nursing services provided or supervised by a RN.
- services of a home health aide for skilled care.
- medical social services provided or supervised by a qualified physician or social worker if your PCP certifies that the medical social services are necessary for the treatment of your medical condition.
- Medically necessary physical, speech, and hearing, or occupational therapy is covered.
- Outpatient hospice services for a plan participant who is terminally ill, which must be pre-certified by Aetna, including:
- counseling and emotional support.
- home visits by nurses and social workers.
- pain management and symptom control.
- instruction and supervision of a family member.
- Note: The Plan does not cover the following hospice services:
- bereavement counseling, funeral arrangements, pastoral counseling, or financial or legal counseling.
- homemaker or caretaker services and any service not solely related to the care of the terminally ill patient.
- respite care when the patient’s family or usual caretaker cannot, or will not, attend to the patient’s needs. Bereavement and respite care may be covered when prior authorization is obtained under Aetna's Compassionate Care Program. Contact Aetna Member Services or a Health Advocate for more information.
- Oral surgery (limited to extraction of bony, impacted teeth, treatment of bone fractures, removal of tumors and orthodontogenic cysts).
- Reconstructive breast surgery following a mastectomy, including:
- reconstruction of the breast on which the mastectomy is performed, including areolar reconstruction and the insertion of a breast implant,
- surgery and reconstruction performed on the non-diseased breast to establish symmetry when reconstructive breast surgery on the diseased breast has been performed, and
- physical therapy to treat the complications of the mastectomy, including lymphedema.
- Infertility services to diagnose and treat the underlying medical cause of infertility. You may obtain the following basic infertility services from a participating gynecologist or infertility specialist without a referral from your PCP:
- initial evaluation, including history, physical exam and laboratory studies performed at an appropriate participating laboratory,
- evaluation of ovulatory function,
- ultrasound of ovaries at an appropriate participating radiology facility,
- postcoital test,
- endometrial biopsy, and
- Semen analysis at an appropriate participating laboratory is covered for male plan participants; a referral from your PCP is necessary.
- If you do not conceive after receiving the above infertility services, or if the diagnosis suggests that there is no reasonable chance of pregnancy as a result of the above services, you are eligible to receive the following Comprehensive Infertility Services through an Institute of Excellence (IOE) when preauthorized through and coordinated by the Aetna Infertility Unit:
- ovulation induction cycles (blood work and ultrasounds), subject to a lifetime maximum of 6 cycles,
- artificial insemination (AID, AIH, IUI), subject to a lifetime maximum of 6 attempts, and
- infertility surgery (diagnostic or therapeutic).
- Members may also be eligible to receive coverage for the following Comprehensive Infertility Services through an IOE upon pre-authorization by Aetna:
- Certain infertility treatments and services known as Advanced Reproductive Technologies (ART, including in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT) and frozen embryo transfer (FET), subject to a $10,000 lifetime limit for each eligible covered participant and only services received at Aetna-designated IOEs will be covered.
- Chiropractic services. Subluxation services must be consistent with Aetna’s guidelines for spinal manipulation to correct a muscular skeletal problem or subluxation that could be documented by diagnostic X-rays performed by a participating radiologist. Chiropractic care limited to 20 visits per year.
- Prosthetic appliances and orthopedic braces (including repair and replacement when due to normal growth). Instruction and appropriate services required to ensure proper use of equipment (such as attachment or insertion). Certain prosthetics require preauthorization by Aetna.
- Telemedicine is a covered medical expense under all of the following conditions: it must be an interaction between a healthcare professional and a covered person via real-time audio-video technology, the originating site must be a physician's or mental health provider's office, a hospital, or a health clinic (e.g., not a residence, personal office or a retail pharmacy), it must consist of "face-to-face" interactive video consultation services wherein the covered person is present, and it must exclude store-and-forward applications, such as teleradiology and remote EKG applications.
- Gender reassignment services are covered as consistent with Aetna's clinical policy bulletins.
Treatment of last resort
In life-threatening situations, experimental or investigational treatment may be considered a covered expense as a treatment of last resort. A person's condition is considered life-threatening if there is a reasonable likelihood that death will result in a matter of months without treatment or that premature death will occur without early treatment. In this case, proposed experimental or investigational treatments will be reviewed by a panel of specialty-matched experts. The review will include factors such as the efficacy of the proposed treatment, the patient's condition, availability and efficacy of other treatments that are approved for the patient's diagnosis, and the prior use of appropriate treatments for the condition.
Treatment of last resort must be authorized by the Administrator-Benefits, and will be based on the fact that the covered person's condition is life-threatening and the treatment is recommended by a panel of specialty-matched physicians chosen to review the treatment.
Inpatient care in a hospital, skilled nursing facility or hospice
If you are hospitalized by a participating PCP or specialist (with prior referral or authorization except in emergencies), you receive the benefits listed below. See Magellan for inpatient mental health and substance abuse benefits.
- Confinement in semi-private accommodations (or private room when medically necessary - private accommodations guidelines will be according to Aetna standard) while confined to an acute care facility.
- Confinement in semi-private accommodations in an extended care/skilled nursing facility.
- Confinement in semi-private accommodations in a hospice care facility for a plan participant who is diagnosed as terminally ill.
- Intensive or special care facilities.
- Visits by your PCP while you are confined.
- General nursing care.
- Surgical, medical and obstetrical services provided by the participating hospital.
- Use of operating rooms and related facilities.
- Medical and surgical dressings, supplies, casts and splints.
- Drugs and medications.
- Intravenous injections and solutions.
- Administration and processing of blood, processing fees and fees related to autologous blood donations. (The blood or blood product itself is not covered.)
- Nuclear medicine.
- Preoperative care and postoperative care.
- Anesthesia and anesthesia services.
- Oxygen and oxygen therapy.
- Inpatient physical and rehabilitation therapy, including:
- cardiac rehabilitation, and
- pulmonary rehabilitation.
- X-rays (other than dental X-rays), laboratory testing and diagnostic services.
- Magnetic resonance imaging.
- Non-experimental, non-investigational transplants. All transplants must be ordered by your PCP and participating specialist and approved in advance by Aetna. Transplants must be performed in hospitals specifically approved and designated by Aetna to perform the procedure. The Institutes of Excellence (IOE) network is Aetna's network of providers for transplants and transplant-related services, including evaluation and follow-up care. Each facility has been selected to perform only certain types of transplants, based on their quality of care and successful clinical outcomes. A transplant will be covered only if performed in a facility that has been designated as an IOE facility for the type of transplant in question. Any facility that is not specified as an Institute of Excellence network facility is considered as an out-of-network facility for transplant-related services, even if the facility is considered as a participating facility for other types of services.
The Plan covers physician and hospital care for mother and baby, including prenatal care, delivery and postpartum care. In accordance with the Newborn and Mothers Healthcare Protection Act, you and your newly born child are covered for a minimum of 48 hours of inpatient care following a vaginal delivery (96 hours following a cesarean section). However, your provider may after consulting with you discharge you earlier than 48 hours after a vaginal delivery (96 hours following a cesarean section).
You do not need a referral from your PCP for visits to your participating obstetrician. A list of participating obstetricians can be found in your provider directory or on DocFind® (see “Provider Information”).
Note: Your participating obstetrician is responsible for obtaining pre-certification from Aetna for all obstetrical care after your first visit. They must request approval (pre-certification or referral) for any tests performed outside of their office and for visits to other specialists. Please verify that the necessary referral or pre-certification has been obtained before receiving such services.
If you are pregnant at the time you join the Plan, you receive coverage for authorized care from participating providers on and after your effective date. There is no waiting period. Coverage for services incurred prior to your effective date with the Plan is your responsibility or that of your previous plan.
Your mental health/substance abuse benefits will be administered by Magellan Healthcare. The Aetna network is not used for mental health or substance abuse care. Magellan Healthcare provides pre-certification of inpatient (which may be required) treatment, provider referral, ongoing consultation and review, and case management for mental health and substance abuse treatment. You do not need a referral from your PCP to obtain care from participating mental health and substance abuse providers. Instead, when you need mental health or substance abuse treatment, call the Magellan Healthcare telephone number shown on your ID card. A clinical care manager will assess your situation and refer you to participating providers, as needed.
Behavioral health treatment
The Plan covers the following services for behavioral health treatment:
- Inpatient medical, nursing, counseling and therapeutic services in a hospital or non-hospital residential facility, appropriately licensed by the Department of Health or its equivalent.
- Short-term evaluation and crisis intervention mental health services provided on an outpatient basis.
Treatment of substance abuse
The Plan covers the following services for treatment of substance abuse:
- Inpatient care for detoxification, including medical treatment and referral services for substance abuse or addiction.
- Inpatient medical, nursing, counseling and therapeutic rehabilitation services for substance abuse or dependency in an appropriately licensed facility.
- Outpatient visits for substance abuse detoxification. Benefits include diagnosis, medical treatment and medical referral services by your PCP.
- Outpatient visits to a participating behavioral health provider for diagnostic, medical or therapeutic rehabilitation services for substance abuse.
- Outpatient treatment for substance abuse or dependency must be provided in accordance with an individualized treatment plan.
The Plan pays, subject to any limitations specified under “Your Benefits,” the cost incurred for outpatient prescription drugs that are obtained from a participating pharmacy. Express Scripts is the pharmacy benefit manager for your prescription drugs. You must present your Express Scripts or Medco ID card and make the co-payment shown in the “Co-payment Schedule” for each prescription at the time the prescription is dispensed.
The Plan covers the costs of prescription drugs, in excess of the co-payment, that are:
- Medically necessary for the care and treatment of an illness or injury, as determined by Express Scripts;
- Prescribed in writing by a physician who is licensed to prescribe federal legend prescription drugs or medicines; and
- Not listed under “Prescription Drug Exclusions and Limitations,” below.
Each prescription is limited to a maximum 30-day supply, with refills as authorized by your physician (but not to exceed one year from the date originally prescribed). Non-emergency prescriptions must be filled at a participating pharmacy. Generic drugs may be substituted for brand-name products where permitted by law.
Coverage is based upon Express Scripts’ formulary. The formulary includes both brand-name and generic drugs and is designed to provide access to quality, affordable outpatient prescription drug benefits. You can reduce your co-payment by using a covered generic or brand-name drug that appears on the formulary. Your co-payment will be highest if your physician prescribes a covered drug that does not appear on the formulary.
Mail order drugs
Participants in the Plan who must take a drug for more than 30 days may obtain up to a 90-day supply of the drug with Express Scripts Pharmacy (www.express-scripts.com), if authorized by their physician. The minimum quantity dispensed by Express Scripts Pharmacy is for a 31-day supply, and the maximum quantity is for a 90-day supply. The co-payment shown in the “Co-payment Schedule” will apply to each mail order purchase.
You may not have access to a participating pharmacy in an emergency or urgent care situation, or if you are traveling outside of the Plan’s service area. If you must have a prescription filled in such situations, the Plan will reimburse you as follows:
- Non-Participating Pharmacy – You must pay the pharmacy directly for the full cost of the prescription and you will be responsible for submitting a request for reimbursement in writing to the pharmacy benefit manager with a receipt for the cost of the prescription. The pharmacy benefit manager will directly reimburse the Member 100% of the prescription, less the applicable co-pay. Coverage for items obtained from non-participating pharmacies is limited to items obtained in connection with covered Emergency and Out-of-Area Urgent Care services. Contact Express Scripts Member Services for more information.
- Participating Pharmacy – When you obtain an emergency or urgent care prescription at a participating pharmacy (including an out-of-area participating pharmacy), you must pay the applicable co-pay. The pharmacy benefit manager will not reimburse claims submitted as a direct reimbursement request from a Member for a prescription purchased at a participating retail pharmacy except upon professional review and approval by the pharmacy benefit manager.
The Plan covers the following:
- Outpatient prescription drugs when prescribed by a provider who is licensed to prescribe federal legend drugs or medicines, subject to the terms, limitations and exclusions described in this booklet.
- FDA-approved prescription drugs when the off-label use of the drug has not been approved by the FDA to treat the condition in question, provided that:
- the drug is recognized for treatment of the condition in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information), or
- the safety and effectiveness of use for the condition has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal.
- Diabetic supplies as follows:
- diabetic needles and syringes
- alcohol swabs
- test strips for glucose monitoring and/or visual reading
- diabetic test agents
- lancets (and lancing devices)
- prescriptive and nonprescriptive oral agents for controlling blood sugar levels
- glucagon emergency kits
- Smoking Cessation aids and drugs prescribed by a physician.
- Oral and implantable contraceptive drugs and contraceptive devices.
- Injectable contraceptives (Depo-Provera).
- Growth hormone therapy, when pre-certified by Express Scripts
Prescription drug exclusions and limitations
Prescription drug exclusions
The following services and supplies are not covered by the Plan, and a medical exception is not available for coverage:
- Any drug that does not, by federal or state law, require a prescription order (such as an over-the- counter drug), even when a prescription is written.
- Any drug that is not medically necessary.
- Charges for the administration or injection of a prescription drug or insulin.
- Cosmetics and any drugs used for cosmetic purposes or to promote hair growth, including (but not limited to) health and beauty aids.
- Any prescription for which the actual charge to you is less than the co-payment.
- Any prescription for which no charge is made to you.
- Insulin pumps or tubing for insulin pumps.
- Medication which is to be taken by you or administered to you, in whole or part, while you are a patient in a licensed hospital or similar facility.
- Take-home prescriptions dispensed from a hospital pharmacy upon discharge from the hospital, unless the hospital pharmacy is a participating retail pharmacy.
- Any medication that is consumed or administered at the place where it is dispensed.
- Immunization or immunological agents, including, but not limited to:
- biological sera.
- blood, blood plasma or other blood products administered on an outpatient basis.
- allergy sera and testing materials.
- Drugs used for the purpose of weight reduction, including the treatment of obesity.
- Any prescription refilled in excess of the number specified by the physician, or any refill dispensed after one year from the physician’s original order.
- Drugs labeled “Caution - Limited by Federal Law to Investigational Use” and experimental drugs.
- Drugs prescribed for uses other than the uses approved by the FDA under the Food, Drug and Cosmetic Law and regulations.
- Medical supplies, devices and equipment, and non-medical supplies and substances, regardless of their intended use.
- Prescription drugs purchased prior to the effective date, or after the termination date, of coverage under this Plan.
- Replacement of lost or stolen prescriptions.
- Prescription drugs or medications used for treatment of sexual dysfunction, including, but not limited to erectile dysfunction, delayed ejaculation, anorgasmy and decreased libido.
- Performance and athletic performance lifestyle-enhancement drugs and supplies.
- Smoking-cessation aids or drugs unless prescribed by a physician.
- Test agents and devices, except diabetic test strips.
- Needles and syringes, except diabetic needles and syringes.
- Any drug or device that terminates a pregnancy.
- Prophylactic drugs for travel.
- Nutritional Supplements.
- Medication packaged in unit dose form (except those approved by payment by Express Scripts).
- Injectable drugs, except insulin. The Plan does not cover:
- injectable drugs used in the treatment of infertility, unless obtained in connection with ART services at an Aetna-designated IOE and approved by Express Scripts.
Prescription drug limitations
The following limitations apply to the prescription drug coverage:
- A participating retail or mail order pharmacy may refuse to fill a prescription order or refill when, in the professional judgment of the pharmacist, the prescription should not be filled.
- Prescriptions may be filled only at a participating retail or mail order pharmacy, except in the event of emergency or urgent care. Plan participants will not be reimbursed for out-of-pocket prescription purchases from a non-participating pharmacy in non-emergency, non-urgent care situations.
- Plan participants must present their ID cards at the time each prescription is filled to verify coverage. If you do not present your ID card, your purchase may not be covered by the Plan, except in emergency and urgent care situations, and you may be required to pay the entire cost of the prescription.
- The plan is not responsible for the cost of any prescription drug for which the actual charge to the plan participant is less than the required co-payment or for any drug for which no charge is made to the recipient.
- Plan participants will be charged the non-formulary prescription drugs co-payment for prescription drugs covered on an exception basis.
- For maintenance medications (those taken on a regular basis to treat ongoing conditions like allergies, asthma, diabetes, heart conditions, etc.), the plan will provide coverage for three fills at a retail pharmacy; for subsequent fills at a retail pharmacy, the participant will be responsible for 100% of the cost. Any refill that is submitted to the Express Scripts mail order pharmacy will be subject to the mail order pharmacy copayments.
- When a clinically equivalent generic is available, and a brand name drug is purchased, the copayment will be equal to the generic copayment amount plus the difference in the cost of the brand name drug and the generic. The difference in cost will not count toward the annual out of pocket maximum for prescription drugs.
Advanced utilization management
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the plan will cover another (usually more expensive) drug. Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.
As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomic parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com to obtain more information about your medications and if they require a coverage review. If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.
Preferred drug step therapy rules
Preferred drug step therapy rules are used for certain therapeutic chapters of drugs, to encourage the use of effective, lower-cost drugs by excluding some targeted medications from coverage. Current therapeutic chapters include: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, glaucoma, diabetes, respiratory allergy/asthma, anti-inflammatory and rheumatoid arthritis, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder (ADHD), prostate therapy drugs, topical steroids, and stroke prevention there will be targeted drugs determined by Express Scripts which will not be covered unless pre-certified by Express Scripts. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic chapters, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.
Prior authorization rules
Prior authorization rules apply to certain therapeutic chapters of drugs; therapies in this section will be monitored for appropriate use, including pharmacogenomics parameters in some cases. These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatologicals and topical pain medications may trigger a prior authorization. Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each chapter as determined by Express Scripts will only be covered to the extent they are authorized by Express Scripts. If you have a question regarding coverage for a drug in any of these therapeutic chapters, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules.
Self-Administered, Rare Disease specialty drugs, and some physician/office based infused drugs such as Anti Inflammatory/Rheumatoloical agents, are only available through the Express Scripts Pharmacy. You will be notified directly by Express Scripts if you are affected by these rules.
Express Scripts’ split fill program applies to certain select specialty conditions where participants often stop or change therapy early in treatment due to side effects or their ability to tolerate treatment. This program will provide smaller initial fills (15-day supply) and clinical support to participants as they begin their therapy. Coinsurance and the per prescription maximum will be applied on a prorated basis so that the participant will not be disadvantaged financially. This program is designed to help manage side-effects, eliminate wasted medications and manage specialty drug costs.