Health Maintenance Organization (HMO)
Policy Face Page
AETNA HEALTH INC.
(a stock company) 151 Farmington Avenue
Hartford, Connecticut 06156
This policy is underwritten by Aetna Health Inc. (called Aetna).
Coverage begins on the policy effective date as stated on the Insert A and will continue until coverage
ends as described under the When coverage ends section of your policy.
This policy provides coverage for services and supplies described as covered benefits that are medically
necessary. This policy applies to coverage only and does not restrict your ability to receive health care
services or prescription drugs that are not or might not be covered benefits under this policy. Please
read this policy, including the attached schedule of benefits, as they explain the benefits in detail.
This policy will be governed by applicable federal laws and the laws of the state of North Carolina.
READ YOUR POLICY CAREFULLY
Important cancellation information
Please read entire When coverage ends section.
This policy is a legal contract between you and Aetna. We agree to insure you and any of your covered
dependents as defined by this policy, in return for your premium payments. Aetna will pay eligible
covered benefits while this policy is in force and after the policy terms have been met.
Right To Examine The policy
You have 10 days after receipt of this policy to examine its provisions. During that 10 day period, if you
are dissatisfied with the policy, it may be returned to Aetna at its Home Office or to the agent from
whom it was purchased. Immediately upon such return, this policy shall be void from the policy effective
date and any premium paid will be refunded.
Guaranteed Availability
This policy is guaranteed availability to an eligible individual desiring to enroll in the individual health
insurance coverage. Aetna will not decline to offer the coverage to, or deny enrollment of, the
individual; or impose any preexisting condition exclusion with respect to the coverage.
Guaranteed Renewable
This policy is guaranteed renewable at premium rates determined by Aetna, subject to the appropriate
regulatory approval. However, Aetna may refuse the renewal under certain conditions, as explained
under the terms of this policy or required by law.
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You may keep this policy in force by meeting the policy eligibility requirements and by making timely
payment of the required premium. See the What does the policy cost you section of the policy for more
information.
Your Application
The application you submitted for coverage has now become part of the policy, which has been issued
relying on the information given in your answers to all questions in the application process for coverage
under this policy.
By applying for coverage under this policy, or accepting its benefits, you (or your representative seeking
coverage on your behalf) represent that all information contained in your application and statements
submitted to Aetna as part of your application for this policy is true, correct and complete, to the best of
your knowledge and belief; and you agree to all terms, conditions and provisions of the policy.
It is your responsibility to review the application that you submitted for accuracy and completeness. It is
important that you notify the Exchange immediately of any inaccurate statements that you find in your
application.
Any intentional misrepresentation of material fact or fraud in the information and/or answers submitted
as part of the application and/or application process (subject to the Honest mistakes and intentional
deception section of this policy) may, at the Exchange’s discretion, result in the rescission of this policy,
and in federal and State prosecution in accordance with federal and State laws.
If you need a copy of your application, it can be obtained by contacting the Exchange at the toll-free
number on your ID card.
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Welcome
Thank you for choosing Aetna.
This is your policy. It is one of two documents that together describe what benefits you have under the
terms of the policy.
This policy is provided following your application for coverage through the state of North Carolina or
federal exchange (the Exchange). Coverage under this policy is subject to any rules, regulations or other
standards set forth by the Exchange and/or the North Carolina Department of Insurance Federal
Department of Health and Human Services (the Department).
This policy will tell you about your covered benefits – what they are and how you get them. The second
document is the schedule of benefits. It tells you how we share expenses for eligible health services and
tells you about limits – like when your policy covers only a certain number of visits.
Oh, and each of these documents may have amendments, inserts or riders attached to them. They
change or add to the documents they’re part of/ They can be delivered at the time the policy is delivered
to you or at another time but whenever received; they are understood to be part of your Aetna policy of
coverage.
Where to next? Flip through the table of contents or try the Let’s get started! section right after it. Let's
get started! gives you a thumbnail sketch of how your policy works. The more you understand, the more
you can get out of your policy.
Welcome to your Aetna policy of coverage.
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Table of Contents
Page
Welcome
Let’s get started!
Some notes on how we use words
What your policy does – providing covered benefits
How your policy works – starting and stopping coverage
How your policy works while you are covered
How to contact us for help
Your member identification (ID) card
Notification of change in residence
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What does the policy cost you?
Premium payment
Grace period
Premium agreement
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Who the policy covers
Who is eligible
Who can be your covered dependent
When a dependent can be added to your policy
Special times your dependent can join the policy
Effective date of coverage for your covered dependent
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Medical necessity, and precertification requirements
Medically necessary; medical necessity
Precertification
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Eligible health services under your policy
1. Preventive care and wellness
2. Physicians and other health professionals
3. Hospital and other facility care
4. Emergency services and urgent care
5. Pediatric dental care
6. Specific conditions
7. Specific therapies and tests
8. Other services
9. Outpatient prescription contraceptive drugs and devices,
Preventive care drugs and supplements and Risk reducing breast cancer
prescription drugs, tobacco cessation prescription and over-the-counter drugs
10. Outpatient prescription drugs
42
What your policy doesn’t cover - some eligible health service exceptions
General exceptions
Additional exceptions for specific types of care
1. Preventive care and wellness
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Physicians and other health professionals
Hospital and other facility care
Emergency services and urgent care
Pediatric dental care
Specific conditions
Specific therapies and tests
Other services
Outpatient prescription contraceptive drugs and devices,
Preventive care drugs and supplements, Risk reducing breast cancer
prescription drugs, tobacco cessation prescription and over-the-counter drugs
10. Outpatient prescription drugs
2.
3.
4.
5.
6.
7.
8.
9.
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Who provides the care
Network providers
Your primary care physician (PCP)
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What the policy pays and what you pay
The general rule
Important exception – when your policy pays all
Important exceptions – when you pay all
Special financial responsibility
Where your schedule of benefits fits in
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When you disagree - claim decisions and appeals procedures
Types of claims and communicating our claim decisions
Adverse benefit determinations
The difference between a complaint and an appeal
Appeals of adverse benefit determinations
Timeframes for deciding appeals
Exhaustion of appeals process
External review
Recordkeeping
Fees and expenses
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When coverage ends
When will your coverage end?
When will coverage end for any covered dependent?
Why would we end your and your covered dependents’ coverage?
When can I expect my coverage to end?
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Special coverage options after your policy coverage ends
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A bit of this and that
Administrative provisions
Coverage and services
Honest mistakes and intentional deception
Some other money issues
Your health information
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Glossary
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Discount programs
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Schedule of benefits
Health Maintenance Organization Policy- Insert A
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Let’s get started!
Here are some basics. First things first – some notes on how we use words. Then we explain how your
policy works so you can get the most out of your coverage. But for all the details – this is very important
– you need to read this entire policy and the schedule of benefits. And if you need help or more
information, we tell you how to reach us.
Some notes on how we use words
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When we say “you” and “your,” we mean the Policyholder as defined in Insert A.
When we say “us”, “we” and “our” we mean Aetna.
Some words appear in bold type. We define them in the Glossary section.
Sometimes we use technical medical language that is familiar to medical providers.
What your policy does – providing covered benefits
Your policy provides covered benefits. These are eligible health services for which your policy has the
obligation to pay.
How your policy works – starting and stopping coverage
Your coverage under the policy has a start and an end. You start coverage after you complete the
eligibility and enrollment process; and the policy has been issued (see the policy effective date on Insert
A). Coverage is not provided for any services received before coverage starts or after coverage ends.
Your coverage typically ends when you no longer pay your premium. A covered dependent can lose
coverage for many reasons, such as growing up and leaving home. To learn more see the When
coverage ends section.
Ending coverage under the policy doesn’t necessarily mean you lose coverage with us. See the Special
coverage options after your policy coverage ends section.
How your policy works while you are covered
Your coverage:
 Helps you get and pay for a lot of – but not all – health care services. These are called
eligible health services.
 Generally will pay only when you get care from the providers listed in our provider
directory.
1. Eligible health services
Doctor and hospital services are the foundation for many other services. You’ll probably find the
preventive care, emergency services and urgent condition coverage especially important. But
the policy won't always cover the services you want. Sometimes it doesn't cover health care
services your doctor will want you to have.
So what are eligible health services? They are health care services that meet these three
requirements:
 They are listed in the Eligible health services under your policy section.
 They are not carved out in the What your policy doesn’t cover – some eligible health service
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exceptions section. (We refer to this section as the “exceptions” section.)
They are not beyond any limits in the schedule of benefits.
2. Aetna’s network of tier 1 and tier 2 doctors, hospitals and other health care providers are there
to give you the care you need. You can find tier 1 network providers and see important
information about them most easily on our online provider directory. Just log into your
my.aetna.com secure member website at www.aetna.com. You will pay less cost share when
you use a tier 1 network provider. Tier 2 network providers are available to you but the cost
share will be at a higher level when these providers are used.
You are encouraged to choose a tier 1 network provider, for your primary care physician (PCP)
to oversee your care. Your PCP will provide your routine care, and send you to other providers
when you need specialized care. You don’t have to access care through your PCP. You may go
directly to network providers for eligible health services. Your plan often will pay a bigger share
for eligible health services that you get through your tier 1 network PCP.
For more information about the network and the role of your PCP, see the Who provides the
care section.
3. Service area
Your policy generally pays for eligible health services only within a specific geographic area,
called a service area. There are some exceptions, such as for emergency services and urgent
care. See the Who provides the care section.
Note: If you have a dependent and they move outside of the service area, their coverage outside
of the service area will be limited to emergency and urgent care services for both medical and
pharmacy services.
4. Paying for eligible health services– the general requirements
There are several general requirements for the policy to pay any part of the expense for an
eligible health service. They are:
 The eligible health service is medically necessary, and
 Your provider precertifies the eligible health service when required.
You will find details on medical necessity and precertification requirements in the Medical
necessity and precertification requirements section. You will find the requirement to use a
directory provider and any exceptions in the Who provides the care section.
5. Paying for eligible health services– sharing the expense
Generally you will share the expense of your eligible health services when you meet the general
requirements for paying.
But sometimes your policy will pay the entire expense; and sometimes you will. For more
information see the What the policy pays and what you pay section, and see the schedule of
benefits.
6. Disagreements
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We know that people sometimes see things differently.
The policy tells you how we will work through our differences.
For more information see the When you disagree - claim decisions and appeals procedures
section.
How to contact us for help
We are here to answer your questions. You can contact us by logging onto your my.aetna.com secure
member website at www.aetna.com.
Register for my.aetna.com, our secure Internet access to reliable health information, tools and
resources. my.aetna.com online tools will make it easier for you to make informed decisions about your
health care, view claims, research care and treatment options, and access information on health and
wellness.
You can also contact us by:
 Calling the Exchange at the toll-free number on your ID card, (844)-241-0208)
 Writing us at Aetna, P.O. Box 14079, Lexington, KY 40512-4079
Your member ID card
Your member ID card tells doctors, hospitals, and other providers that you are covered by this
policy. Show your ID card each time you get health care from a provider to help them bill us
correctly and help us better process their claims.
Remember, only you and your covered dependents can use your member ID card. If you misuse your
card we may end your coverage.
You can obtain your electronic ID card or print a temporary ID card. Just log into your my.aetna.com
secure member website at www.aetna.com or calling Member Services.
For this reason and others, it is important to insure you notify us of any changes in status, for
example:
 a change of address or phone number
 a change of your covered dependent status
 a marriage or divorce or any partnership changes.
This will help us effectively provide your benefits- please notify us as soon as possible of any status
change listed above.
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Notice of Change in Residence
It is important that you notify Aetna within 31 days if you change your address. If you move outside of
the State of North Carolina, and Aetna is participating in an Exchange and has a plan in that state ,
Aetna will issue you a policy with comparable coverage as of the beginning of the premium period in
which the change occurs, without a lapse in coverage. The premium for the new coverage will be based
upon the premium rates for your new state of residence, and the attained ages of the covered
dependents.
If you move within the Exchange service area, premium rates will be adjusted, if necessary, to adjust to
your new address and the current ages of your covered dependents, effective at the beginning of the
premium period following the change of residence.
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What does the policy cost you?
Premium payment
This policy requires you to make premium payments. We will not pay benefits under this policy if
premium payments are not made by the end of the grace period. Any benefit payment denial is subject
to our appeals procedure. See the When you disagree - complaints and appeals procedures section of
this policy.
The first premium payment is due on or before your or your covered dependent’s effective date of
coverage. The cost of your and your covered dependent coverage is listed on Insert A.
Your subsequent premium payment shall be due on the 1st of each month based on your effective date
of coverage. Each premium payment is to be paid to us on or before the due date. Your premium
becomes overdue following the last day of the premium period.
We issued this policy to you in exchange for premium paid by you. Aetna reserves the right to not
accept premium paid by third parties, provided that we will always accept premium paid by the
following third parties: a) Ryan White HIV/AIDS Program under title XXVI of the Public Health Service
Act; b) Indian tribes, tribal organizations or urban Indian national organizations; and c) State and Federal
Government programs.
Grace period
You will be allowed a grace period of 31 days after the due date for the payment of each premium due
after the first premium payment. If premiums are not paid by the end of the grace period, your
coverage will automatically terminate at the end of the grace period, unless expressly required by law.
We have the right to require the return of any payments for claims paid during the grace period for
which premium was not received. If this policy is terminated for nonpayment and you request
reinstatement, all past due and current premium must be paid in full in order to be reinstated.
Reinstatement will be as allowed by and in accordance with the Health Insurance Marketplace.
In the event a premium payment check is returned or dishonored by the bank as non-payable to us for
any reason, you may be responsible for an additional charge.
FOR RECIPIENTS OF ADVANCE PAYMENTS OF THE PREMIUM TAX CREDIT, AS DETERMINED BY THE
FEDERAL MARKETPLACE OR A STATE BASED MARKETPLACE, THE FOLLOWING APPLIES RATHER THAN
THE ABOVE SECTION
If you are currently receiving an advance payment of the premium tax credit, and you have paid at least
one full month’s premium during the benefit year, then you will have a grace period of three
consecutive months. Coverage will remain in force during the grace period. However, for an individual
receiving an advanced payment of the premium tax credit, we may pend claims for services rendered
during the second and third months of the grace period. If claims are pended, Aetna will notify you and
providers of the possibility that such claims may not be paid.
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If premium is not received by the end of the last day of the third month of this extended grace period,
your coverage may be cancelled. If cancelled, your coverage will end as of the end of the last day of the
first month of your grace period. We have the right to require the return of any payments for claims
paid during the second and third months of the grace period for which premium was not received.
In the event a premium payment check is returned or dishonored by the bank as non-payable
to us for any reason, you may be responsible for an additional charge.
Premium agreement
Premiums for this policy may be changed. Any change in premium will apply to all covered persons with
your same policy type based on the issue state of your policy. Any change in premium may occur on the
next premium due date after we give you at least 30 days advance notice in writing of such premium
change.
Your premium rate will not change for the initial month of this policy provided that there are no changes
to this policy, including your area of residence, benefit plan or addition of dependents. However, if
there is a change in law or regulation or a judicial decision that has an impact on the cost of providing
your covered benefits under this policy, we reserve the right to change your premium rate during this
guarantee period.
Your premium rate is based upon factors such as:
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Type and level of benefit plan;
Your age and the ages of covered dependents;
The number of covered persons;
Tobacco use; and
Place of residence.
Premium rates are expected to change over time as the cost of healthcare services change. We have the
right to change premium rates at any time in the future, subject to applicable regulatory review. Each
premium will be based on the rates in effect on that premium due date.
In the event of such change, you will receive a notice via U.S.mail at your last known address. Any such
change will take effect on the first (1st) of the month following approval from the North Carolina
Department of Insurance, as necessary, following the required forty-five (45) day period.
In the event of any changes in premium rates, payment of the premium by the policyholder shall serve
as notice of the policyholder’s acceptance of such changes.
We issued this policy to you in exchange for premium paid by you. Aetna reserves the right to not
accept premium paid by third parties, provided that we will always accept premium paid by the
following third parties: a) Ryan White HIV/AIDS Program under title XXVI of the Public Health Service
Act; b) Indian tribes, tribal organizations or urban Indian national organizations; and c) State and Federal
Government programs.
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Who the policy covers
The eligibility process and enrollment process subject to any rules, regulations or other standards set
forth by the Exchange and/or the North Carolina Department of Insurance Federal Department of Health
and Human Services (the Department).
You will find information in this section about:
 Who is eligible
 Who can be your covered dependent
 When a dependent can be added to your policy
 Special times your dependent can join the policy
 Effective date of coverage for your covered dependent
Who is eligible
You are eligible (as the policyholder) to apply to the Exchange and have met their requirements
Who can be your covered dependent
An eligible dependent is one of the following types of family members approved by the Exchange. They
can include:
 Your spouse; or
 Your domestic partner;
 Children age 26 or older, who are physically or mentally unable to earn a living, the incapacity
must have occurred before age 26;
 Newborn, Legally adopted or foster children under age 26;
 Children under age 26 if you or your spouse is the legal guardian;
 Your or your covered spouse’s, or your covered domestic partner’s children who are under 26
years of age; and
 Not eligible for or enrolled in Medicare at the time of application.
When a dependent can be added to your policy
You can enroll your dependent:
 at initial enrollment; or
 at other special times during the year as listed below
 when you have not chosen any of the options below, the default will be on the date of birth,
adoption, placement for adoption, placement in foster care.
Special times your dependent can join the policy
You can enroll a dependent in these situations known as qualifying events:
• When you did not enroll them in this policy during the initial enrollment because:
They become a dependent through marriage, birth, adoption, or foster care
They had other coverage and now that other coverage has ended.
They are eligible or not eligible for advance payments of the premium tax credit, or change
in eligibility for cost-sharing reductions, through the Exchange
They are eligible as a result of a change of address
The person is an Indian, as defined by the Indian Health Care Improvement Act, may enroll
in a qualified health plan (QHP) or change from one QHP to another one time per month
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They demonstrate that they meet other exceptional circumstances according to the
Exchange
You can add the following new dependent any time during the year:
• A spouse - If you marry, you can put a spouse on your policy.
 A domestic partner - If you enter a domestic partnership, you can add a domestic partner to
your policy.
• A newborn child - Your newborn child is covered by your policy for the first 31 days after birth.
Coverage of your newborn will include treatment of injury or illness, including medically
diagnosed congenital defects and birth abnormalities.
To continue coverage beyond this initial period, the child must be enrolled within 60 days of
the date of birth.
If coverage does not require the payment of an additional premium for a covered
dependent, you must still enroll the child within 60 days of the date of birth. so that we may
send an identification card to facilitate the child’s access to covered benefits.
You must enroll the child within 60 days of birth when coverage requires payment of an
additional premium for the covered dependent.
If you miss this deadline, your newborn will not have health benefits after the first 31 days.
 An adopted child - that you, or you and your spouse or domestic partner adopt is covered for
the first 31 days from the date of placement .
- Coverage of your adopted child will include treatment of injury or illness, including medically
diagnosed congenital defects and birth abnormalities
- To continue coverage beyond this initial period, the child must be enrolled within 60 days of
the date on which the child was placed for adoption.
If coverage does not require the payment of an additional premium for a dependent child,
you must still enroll the child within 60 days of the date child was placed for adoption so
that we may send an identification card to facilitate the child’s access to covered benefits.
You must enroll the child within 60 days of date of placement when coverage requires
payment of an additional premium for the covered dependent.
If you miss this deadline, your adopted child or child placed for adoption will not have health
benefits after the first 31 days.
• A stepchild - You may add a child of your spouse or domestic partner to your policy.
The child is covered for the first 31 days after the date of your marriage or your Declaration
of Domestic Partnership with your stepchild’s parent along with the additional premium
required.
- To continue coverage beyond the initial period you must enroll the child within 60 days of
date of placement when coverage requires payment of an additional premium for the
covered dependent.
If coverage does not require the payment of an additional premium for a dependent child,
you must still enroll the child within 60 days of the placement so that we may send an
identification to facilitate the child’s access to covered benefits.
You must enroll the child within 60 days of date of placement when coverage requires
payment of an additional premium for the covered dependent.
If you miss this deadline, your adopted child or child placed for adoption will not have health
benefits after the first 31 days.
• A foster child - You may add a foster child to your policy.
You must complete your enrollment information and send it to us within 31 days from the
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date of placement along with the additional premium required.
To continue coverage beyond this initial period you must enroll the child within 60 days of
date of placement when coverage requires payment of an additional premium for the
covered dependent.
If coverage does not require the payment of an additional premium for a dependent child,
you must still enroll the child within 60 days of the placement so that we may send an
identification card to facilitate the child’s access to covered benefits.
You must enroll the child within 60 days of date of placement when coverage requires
payment of an additional premium for the covered dependent.
If you miss this deadline, your adopted child or child placed for adoption will not have health
benefits after the first 31 days.
Effective date of coverage for your covered dependent
Your dependent coverage will be in effect on the policyholder’s effective date of coverage , if you
enrolled them at that time, otherwise;
 On the date of birth, adoption, placement for adoption or the date of legal placement, or
 On the first day of the first calendar month following receipt of your completed enrollment
application and additional required premium for qualifying events such as marriage or domestic
partnership.
Enrollment/Effective Dates.
You are eligible to enroll under the plan during the annual enrollment and special enrollment periods as
defined by the Exchange. Your enrollment will be effective as of the date provided by the Exchange
The effective date will be a future first (1st) day of the month effective date, based on the date of receipt
of a completed application and assigned by Aetna consistent with the timeframes and will be consistent
with the timeframes set forth in 45 CFR 155.420.
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Medical necessity and precertification requirements
The starting point for covered benefits under your policy is whether the services and supplies are
eligible health services. See the Eligible health services under your policy and exceptions sections plus
the schedule of benefits.
Your policy pays for its share of the expense for eligible health services only if the general requirements
are met. They are:
 The eligible health service is medically necessary.
 Your provider precertifies the eligible health service when required.
This section addresses the medical necessity and precertification requirements.
Medically necessary; medical necessity
As we said in the Let's get started! section, medical necessity is a requirement for you to receive a
covered benefit under this policy.
The medical necessity requirements are stated in the Glossary section, where we define "medically
necessary, medical necessity."
Precertification
You need pre-approval from us for some eligible health services. Pre-approval is also called
precertification.
Your physician or PCP is responsible for obtaining any necessary precertification before you get the
care. If your physician or PCP doesn't get a required precertification, we won't pay the provider who
gives you the care. You won't have to pay either if your physician or PCP fails to ask us for
precertification. If your physician or PCP requests precertification and we refuse it, you can still get the
care but the policy won’t pay for it. You will find details on requirements in the What the policy pays and
what you pay - Important exceptions – when you pay all section.
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Eligible health services under your policy
The information in this section is the first step to understanding your policy's eligible health services.
Your policy covers many kinds of health care services and supplies, such as physician care and hospital
stays. But sometimes those services are not covered at all or are covered only up to a limit.
For example,
 Home health care is generally covered but it is a covered benefit only up to a set number of
visits a year. This is a limitation.
You can find out about these exceptions in the exceptions section, and about the limitations in the
schedule of benefits.
We've grouped the health care services below to make it easier for you to find what you're looking for.
1. Preventive care and wellness
This section describes the eligible health services and supplies available under your policy when you are
well.
Important notes:
1. You will see references to the following recommendations and guidelines in this section:
• Advisory Committee on Immunization Practices of the Centers for Disease Control and
Prevention
• United States Preventive Services Task Force
• Health Resources and Services Administration
 American Academy of Pediatrics/Bright Futures/Health Resources and Services
Administration guidelines for children and adolescents
These recommendations and guidelines may be updated periodically. When these are updated,
they will be applied to this policy. The updates will be effective on the first day of the effective
date of your coverage, one year after the updated recommendation or guideline is issued.
2. Diagnostic testing will not be covered under the preventive care benefit. For those tests, you will
pay the cost sharing specific to eligible health services for diagnostic testing.
3. Gender-specific Preventive care and wellness – eligible health services include any recommended
Preventive care and wellness benefits described below that are determined by your provider to
be medically necessary, regardless of the sex you were assigned at birth, your gender identity, or
your recorded gender.
4. To learn what frequency and age limits apply to routine physical exams and routine cancer
screenings, contact your physician or contact Member Services by logging on to your
my.aetna.com secure member website at www. aetna.com or at the toll-free number on your ID
card. This information can also be found at the www.HealthCare.gov website.
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Routine physical exams
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Eligible health services include office visits to your physician, PCP or other health professional for
routine physical exams. This includes routine vision and hearing screenings given as part of the exam. A
routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a
suspected or identified illness or injury, and also includes:
Evidence-based items that have in effect a rating of A or B in the current recommendations of the
United States Preventive Services Task Force
Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and
Services Administration guidelines for children and adolescents
Screenings and counseling services as provided for in the comprehensive guidelines recommended by
the Health Resources and Services Administration. These services may include but are not limited to:
- Screening and counseling services on topics such as:
o Interpersonal and domestic violence
o Sexually transmitted diseases
o Human Immune Deficiency Virus (HIV) infections
- Screening for gestational diabetes for women
- High risk Human Papillomavirus (HPV) DNA testing for women age 30 and older.
Radiological services, lab and other tests given in connection with the exam
For covered newborns, an initial hospital checkup
Preventive care immunizations
Eligible health services include immunizations provided by your physician, PCP for infectious diseases
recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control
and Prevention.
Your policy does not cover immunizations that are not considered preventive care, such as those
required due to your employment or travel.
Well woman preventive visits
Eligible health services include your routine:
Well woman preventive exam office visit to your physician, PCP obstetrician (OB), gynecologist (GYN) or
OB/GYN for women ages 13 and older. This includes Pap smears. Your policy covers the exams
recommended by the Health Resources and Services Administration. A routine well woman preventive
exam is a medical exam given for a reason other than to diagnose or treat a suspected or identified
illness or injury.
 Preventive care breast cancer (BRCA) gene blood testing by a physician and lab.
 Preventive breast cancer genetic counseling provided by a genetic counselor to interpret the test results
and evaluate treatment.
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Preventive screening and counseling services
Eligible health services include screening and counseling by your health professional for some
conditions. These are obesity, misuse of alcohol and/or drugs, use of tobacco products, sexually
transmitted infection counseling and genetic risk counseling for breast and ovarian cancer. Your policy
will cover the services you get in an individual or group setting. Here is more detail about those benefits.
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Obesity and/or healthy diet counseling
Eligible health services include the following screening and counseling services to aid in weight
reduction due to obesity:
- Preventive counseling visits and/or risk factor reduction intervention
- Nutritional counseling
- Healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and
other known risk factors for cardiovascular and diet-related chronic disease
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Misuse of alcohol and/or drugs
Eligible health services include the following screening and counseling services to help prevent or
reduce the use of an alcohol agent or controlled substance:
- Preventive counseling visits
- Risk factor reduction intervention
- A structured assessment
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Use of tobacco products
Eligible health services include the following screening and counseling services to help you to stop the
use of tobacco products:
- Preventive counseling visits
- Treatment visits
- Class visits
Tobacco product means a substance containing tobacco or nicotine such as:
- Cigarettes
- Cigars
- Smoking tobacco
- Snuff
- Smokeless tobacco
- Candy-like products that contain tobacco
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Sexually transmitted infection counseling
Eligible health services include the counseling services to help you prevent or reduce sexually
transmitted infections.
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Genetic risk counseling for breast and ovarian cancer
Eligible health services include the counseling and evaluation services to help you assess whether or not
you are at increased risk for breast and ovarian cancer.
Routine cancer screenings
Eligible health services include the following routine cancer screenings:
 Mammograms
- One baseline mammogram for a woman age 35 through 39
- One mammogram every other year for a woman age 40 through 49 or more frequently upon
recommendation of a physician
 Prostate specific antigen (PSA) tests or equivalent tests for the presence of prostate cancer means
the serological tests for determining the presence of prostate cytoplasmic protein (PSA) and the
generation of antibodies to it
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Digital rectal exams
Fecal occult blood tests
Sigmoidoscopies
Double contrast barium enemas (DCBE)
Colonoscopies which includes removal of polyps performed during a screening procedure
Lung cancer screenings
Cervical cancer screenings
- covered services include a pelvic exam, examinations and laboratory tests for screening for
cervical cancer in accordance with the most recently published American Cancer Society
guidelines or guidelines adopted by the North Carolina Advisory Committee on Cancer
Coordination and Control. Coverage includes the examination, the laboratory fee and the
laboratory results.
Ovarian cancer screenings
- covered services include surveillance tests for women age 25 and older at risk for ovarian
cancer. At risk for ovarian cancer means either having a family history with at least one firstdegree relative with ovarian cancer; and a second relative, either first-degree or second degree
with breast, ovarian or nonpolyposis colorectal cancer; or testing positive for a hereditary
ovarian cancer syndrome.
o Surveillance tests mean annual screening using:
 Transvaginal ultrasound; and
 Rectovaginal pelvic examination
If you need a routine gynecological exam performed as part of a cancer screening, you may go directly
to a network OB, GYN or OB/GYN.
These benefits will be subject to any age, family history and frequency guidelines that are:
 Evidence-based items or services that have in effect a rating of A or B in the recommendations of
the United States Preventive Services Task Force
 Evidence-informed items or services provided in the comprehensive guidelines supported by the
Health Resources and Services Administration
Prenatal care
Eligible health services include your routine prenatal physical exams as Preventive Care, which includes
the initial and subsequent physical exam services such as:
 Maternal weight
 Blood pressure
 Fetal heart rate check
 Fundal height
You can get this care at your physician's, PCP’s, OB's, GYN's, or OB/GYN’s office.
Important note:
You should review the benefit under Eligible health services under your policy - Maternity and
related newborn care and the exceptions sections of this policy for more information on coverage
for pregnancy expenses under this policy.
Comprehensive lactation support and counseling services
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Eligible health services include comprehensive lactation support (assistance and training in breast
feeding) and counseling services during pregnancy or at any time following delivery for breast-feeding.
Your policy will cover this when you get it in an individual or group setting. Your policy will cover this
counseling only when you get it from a certified lactation support provider.
Breast feeding durable medical equipment
Eligible health services include renting or buying durable medical equipment you need to pump and
store breast milk as follows:
Breast pump
Eligible health services include:
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Renting a hospital grade electric pump while your newborn child is confined in a hospital.
The buying of:
- An electric breast pump (non-hospital grade). Your policy will cover this cost once every three
years or
- A manual breast pump. Your policy will cover this cost once per pregnancy.
If an electric breast pump was purchased within the previous three year period, the purchase of another
electric breast pump will not be covered until a three year period has elapsed since the last purchase.
Breast pump supplies and accessories
Eligible health services include breast pump supplies and accessories. These are limited to only one
purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new
pump or if the initial electric breast pump is broken and out of warranty.
Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same
or similar purpose. Including the accessories and supplies needed to operate the item. You are
responsible for the entire cost of any additional pieces of the same or similar equipment you purchase
or rent for personal convenience or mobility.
Family planning services – female contraceptives
Eligible health services include family planning services such as:
Counseling services
Eligible health services include counseling services provided by a physician, PCP, OB, GYN, or
OB/GYN on contraceptive methods. These will be covered when you get them in either a group or
individual setting.
Devices
Eligible health services include contraceptive devices (including any related services or supplies)
when they are provided by, administered or removed by a physician during an office visit.
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Voluntary sterilization
Eligible health services include charges billed separately by the provider for female voluntary
sterilization procedures and related services and supplies. This also could include tubal ligation and
sterilization implants.
Important note:
See the following sections for more information:
 Family planning services - other
 Maternity and related newborn care
 Outpatient prescription contraceptive drugs and devices, Preventive care drugs and
supplements and Risk reducing breast cancer prescription drugs
 Treatment of basic infertility
2. Physicians and other health professionals
Physician services
Eligible health services include services by your physician to treat an illness or injury. You can get those
services:
 At the physician’s office
 In your home
 In a hospital
 From any other inpatient or outpatient facility
 By way of telemedicine
Important note:
Your policy covers telemedicine only when you get your telephone or internet-based consult
through an authorized internet service vendor who conducts telemedicine consultations that has
contracted with Aetna to offer these services. www.aetna.com/individuals-families/cb/north­
carolina/provider-search/caromont-health-hpn.html tells you who those are. Telemedicine is not
the same as office visits and may have different cost sharing. See the schedule of benefits for
specific policy details.
Other services and supplies that your physician may provide:
 Allergy testing and allergy injections
 Radiological supplies, services, and tests
Physician surgical services
Eligible health services include the services of:
 The surgeon who performs your surgery
 Your surgeon who you visit before and after the surgery
 Another surgeon who you go to for a second opinion before the surgery
Alternatives to physician office visits
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Walk-in clinic
Eligible health services include health care services provided in walk-in clinics for:
 Unscheduled, non-medical emergency illnesses and injuries
 The administration of immunizations administered within the scope of the clinic’s license
 Individual screening and counseling services to aid you:
- In weight reduction due to obesity and/or healthy diet
- To stop the use of tobacco products
- In stress management
The stress management counseling sessions will:
- Help you to identify the life events which cause you stress (the physical and mental strain on your
body).
- Teach you techniques and changes in behavior to reduce the stress.
3. Hospital and other facility care
Hospital care
Eligible health services include inpatient and outpatient hospital care.
The types of hospital care services that are eligible for coverage include:
 Room and board charges up to the hospital’s semi-private room rate. Your policy will cover the
extra expense of a private room when appropriate because of your medical condition.
 Services of physicians employed by the hospital
 Operating and recovery rooms
 Intensive or special care units of a hospital
 Administration of blood and blood derivatives, but not the expense of the blood or blood
product
 Radiation therapy
 Cognitive rehabilitation
 Speech therapy, physical therapy and occupational therapy
 Oxygen and oxygen therapy
 Radiological services, laboratory testing and diagnostic services
 Medications
 Intravenous (IV) preparations
 Discharge planning
 Services and supplies provided by the outpatient department of a hospital.
Anesthesia and hospital or ambulatory surgical facility charges for dental care
Eligible health services include anesthesia for a dental procedure be done in a hospital or ambulatory
surgery center if you:
 Have a serious mental or physical condition that requires that
 Have significant behavioral problems
 Are under 9 years old; and
 Where the provider treating the patient involved certifies that, because of the patient’s age or
condition or problem, hospitalization or general anesthesia is required in order to safely and
effectively perform the procedures.
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Alternatives to hospital stays
Outpatient surgery
Eligible health services include services provided and supplies used in connection with outpatient
surgery performed in a surgery center or a hospital’s outpatient department.
Important note:
Some surgeries can be done safely in a physician’s office. For those surgeries, your policy will pay
only for physician, PCP services and not for a separate fee for facilities.
Home health care and skilled behavioral health services in the home
Eligible health services include home health care services and skilled behavioral health services
provided by a home health agency in the home, but only when all of the following criteria are met:
Home health care services
You are homebound.
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Your physician orders them.
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The services take the place of your needing to stay
in a hospital or a skilled nursing facility, or
needing to receive the same services outside your
home.
The services are part of a home health care plan. 
Skilled behavioral health services in the home
You are homebound.
Your physician orders them.
The services take the place of your needing to stay
in a hospital or a residential treatment facility, or
needing to receive the same services outside your
home.
The services are part of an active treatment plan
of care.
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The services are skilled nursing services, home 
health aide services or medical social services, or
are short-term speech, physical or occupational
therapy.
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.
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If you are discharged from a hospital or skilled
nursing facility after a stay, the intermittent
requirement may be waived to allow coverage for
continuous skilled nursing services. See the
schedule of benefits for more information on the
intermittent requirement.
Home health aide services are provided under the
supervision of a registered nurse.
Medical social services are provided by or
supervised by a physician or social worker.
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Short-term physical, speech and occupational therapy provided in the home are subject to the
conditions and limitations imposed on therapy provided outside the home. See the Short-term
rehabilitation services and Habilitation therapy services sections and the schedule of benefits.
Home health care services do not include custodial care or applied behavior analysis.
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Hospice care
Eligible health services include inpatient and outpatient hospice care when given as part of a hospice
care program.
The types of hospice care services that are eligible for coverage include:
 Room and board
 Services and supplies furnished to you on an inpatient or outpatient basis
 Services by a hospice care agency or hospice care provided in a hospital
 Bereavement counseling
 Respite care
Hospice care services provided by the providers below may be covered, even if the providers are not an
employee of the hospice care agency responsible for your care:
 A physician for consultation or case management
 A physical or occupational therapist
 A home health care agency for:
- Physical and occupational therapy
- Medical supplies
- Outpatient prescription drugs
- Psychological counseling
- Dietary counseling
Outpatient and inpatient skilled nursing care
Eligible health services include services provided by an R.N., L.P.N., or nursing agency for outpatient and
inpatient skilled nursing care. This is care by a visiting R.N., or L.P.N. to perform specific skilled nursing
tasks.
Your policy also covers private duty nursing provided by an R.N. or L.P.N. for non-hospitalized acute
illness or injury if your condition requires skilled nursing care and visiting nursing care is not adequate.
Skilled nursing facility
Eligible health services include inpatient skilled nursing facility care.
The types of skilled nursing facility care services that are eligible for coverage include:
 Room and board, up to the semi-private room rate
 Services and supplies that are provided during your stay in a skilled nursing facility
For your stay in a skilled nursing facility to be eligible for coverage, the following conditions must be
met:
 The skilled nursing facility admission will take the place of:
An admission to a hospital or sub-acute facility.
A continued stay in a hospital or sub-acute facility.
 There is a reasonable expectation that your condition will improve enough to go home within a
reasonable amount of time.
 The illness or injury is severe enough to require constant or frequent skilled nursing care on a
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24-hour basis.
4. Emergency services and urgent care
Eligible health services include services and supplies for the treatment of an emergency medical
condition or an urgent condition.
As always, you can get emergency care from network providers. However, you can also get emergency
care from out-of-network providers.
Your coverage for emergency services and urgent care from out-of-network providers ends when
Aetna and the attending physician determine that you are medically able to travel or to be
transported to a network provider if you need more care.
In case of a medical emergency
When you experience an emergency medical condition, you should go to the nearest emergency room.
You can also dial 911 or your local emergency response service for medical and ambulance assistance. If
possible, call your physician, PCP to discuss treatment options but only if a delay will not harm your
health.
Non-emergency condition
If you go to an emergency room for what is not an emergency medical condition, the policy may not
cover your expenses. See the schedule of benefits and the exception- Emergency services and urgent
care and Precertification sections for specific policy details.
In case of an urgent condition
Urgent condition within the service area
If you need care for an urgent condition while within the service area, you should first seek care
through your physician, PCP. If your physician, PCP is not reasonably available to provide services, you
may access urgent care from an urgent care facility within the service area.
Urgent condition outside the service area
You are covered for urgent care obtained from a facility outside of the service area if you are
temporarily absent from the service area and getting the health care service cannot be delayed until
you return to the service area.
Non-urgent care
If you go to an urgent care facility for what is not an urgent condition, the policy may not cover your
expenses. See the exception –Emergency services and urgent care and Precertification sections and the
schedule of benefits for specific policy details.
5. Pediatric dental care
Eligible health services include dental services and supplies provided by a dental provider. The eligible
health services are those listed in the pediatric dental care section of the schedule of benefits and
provided to covered persons to the end of the month in which the covered child turns 19. We have
grouped them as Type A, B and C, and orthodontic treatment services in the schedule of benefits.
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Eligible health services also include dental services provided for a dental emergency. Services and
supplies provided for a dental emergency will be covered even if services and supplies are provided by
an out-of- network provider.
A dental emergency is any dental condition which:
 Occurs unexpectedly
 Requires immediate diagnosis and treatment in order to stabilize the condition
 Is characterized by symptoms such as severe pain and bleeding
The policy pays a benefit up to the Dental Emergency Maximum, shown in the schedule of benefits.
If you have a dental emergency, you may get treatment from any dentist. You should consider calling
your dental provider who may be more familiar with your dental needs. If you cannot reach your dental
provider or are away from home, you may get treatment from any dentist. You may also call Member
Services for help in finding a dentist. The care received from an out-of-network provider must be for
the temporary relief of the dental emergency until you can be seen by your dental provider. Services
given for other than the temporary relief of the dental emergency by an out-of-network provider can
cost you more. To get the maximum level of benefits, services should be provided by your network
provider.
What rules and limits apply to dental care?
Several rules apply to the dental benefits. Following these rules will help you use the policy to your
advantage by avoiding expenses that are not covered by the policy.
When is there a waiting period?
The policy has a waiting period for:
 Orthodontic treatment: Your coverage will take effect after 24 months of continuous coverage
under the policy.
When does your policy cover orthodontic treatment?
Orthodontic Treatment Rule
Orthodontic treatment is covered when it is medically necessary for a covered person with a severe,
dysfunctional, handicapping condition such as:
 Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement
 The following craniofacial anomalies:
- Hemifacial microsomia
- Craniosynostosis syndromes
- Cleidocranial dental dysplasia
- Arthrogryposis
- Marfan syndrome
 Anomalies of facial bones and/or oral structures
 Facial trauma resulting in functional difficulties
If you suffer from one of these conditions, the orthodontic services that are eligible for coverage
include:
 Pre-orthodontic treatment visit
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Comprehensive orthodontic treatment Orthodontic retention (removal of appliances, construction and placement of retainers(s)
When does your policy cover replacements?
Crowns, inlays, onlays and veneers, complete dentures, removable partial dentures, fixed partial
dentures (bridges) and other prosthetic services are subject to the policy's “replacement rule.“ The
replacement rule is that certain replacements of, or additions to, existing crowns, inlays, onlays and
veneers, dentures or bridges are covered only when you give us proof that:
 You had a tooth (or teeth) extracted after the existing denture or bridge was installed. As a
result, you need to replace or add teeth to your denture or bridge.
 The present crown, inlay, onlay and veneer, complete denture, removable partial denture, fixed
partial denture (bridge), or other prosthetic service was installed at least 3-8 years before its
replacement and cannot be fixed.
 You had a tooth (or teeth) extracted. Your present denture is an immediate temporary one that
replaces that tooth (or teeth). A permanent denture is needed, and the temporary denture
cannot be used as a permanent denture. Replacement must occur within 12 months from the
date that the temporary denture was installed.
When does your policy cover missing teeth that are not replaced?
The installation of complete dentures, removable partial dentures, fixed partial dentures (bridges), and
other prosthetic services if:
 The dentures, bridges or other prosthetic items are needed to replace one or more natural
teeth. (The extraction of a third molar tooth does not qualify.)
 The tooth that was removed was not an abutment to a removable or fixed partial denture
installed during the prior 8 years.
Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.
When does your policy cover other treatment?
Sometimes there are several ways to treat a dental problem, all of which provide acceptable results.
When alternate services or supplies can be used, the policy's coverage will be limited to the expense of
the least expensive service or supply that is:
 Customarily used nationwide for treatment.
 Deemed by the dental profession to be appropriate for treatment of the condition in question.
The service or supply must meet broadly accepted standards of dental practice, taking into
account your current oral condition.
You should review the differences in the expense of alternate treatment with your dental provider. Of
course, you and your dental provider can still choose the more expensive treatment method. You are
responsible for any charges in excess of what the policy will cover.
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6. Specific conditions
All clinical treatment options will be discussed with you as they relate to any specific condition.
Congenital Defects or Anomalies (including cleft lip/palate)
The Plan covers congenital defects or anomalies for children the same as are provided for most
childhood sicknesses or illnesses. Benefits include all necessary treatment and care for cleft lip or cleft
palate for children less than 18 years of age.
Diabetic equipment, supplies and education
Eligible health services include:
 Services and supplies
- Foot care to minimize the risk of infection
- Insulin preparations
- Diabetic needles and syringes
- Injection aids for the blind
- Diabetic test agents
- Lancets/lancing devices
- Prescribed oral medications whose primary purpose is to influence blood sugar
- Alcohol swabs
- Injectable glucagons
- Glucagon emergency kits
 Equipment
- External insulin pumps
- Blood glucose monitors without special features, unless required due to blindness
 Training
- Outpatient self-management training provided by a health care provider certified in diabetes
self-management training
This coverage is for the treatment of insulin (type I) and non-insulin dependent (type II) diabetes and the
treatment of elevated blood glucose levels during pregnancy.
Bones and Joints of the jaw, face or head treatment
Eligible health services include the diagnosis and surgical treatment of a jaw joint disorder by a
provider which includes:

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the jaw joint itself, such as temporomandibular joint dysfunction (TMJ) syndrome includes
splinting and use of intraoral prosthetic appliances to reposition the bones; or
involving the relationship between the jaw joint and related muscles and nerves such as
myofacial pain dysfunction (MPD)
Procedures involving the bones or joints of the jaw, face or head are covered on the same basis as any
bone or joint in the body.
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Maternity
Inpatient hospital stay
Eligible health services include prenatal and postpartum care, obstetrical services and complications of
pregnancy. After your child is born, eligible health services include:
 48 hours of inpatient care in a network hospital after a vaginal delivery
 96 hours of inpatient care in a network hospital after a cesarean delivery
 A shorter stay, if the attending physician, with the consent of the mother, discharges the
mother or newborn earlier. Upon request, We will schedule post-delivery follow-up care within
72 hours after discharge
Coverage also includes the services and supplies needed for circumcision by a provider.
Complications of pregnancy
Complications of pregnancy are those conditions that pose a significant threat to the health of the
mother or baby, including:
 Hyperemesis gravidarum (pernicious vomiting of pregnancy)
 Toxemia with convulsions
 Severe bleeding before delivery due to premature separation of the placenta from any cause
 Bleeding after delivery severe enough to need a transfusion or blood
 Amniotic fluid tests, analyses, or intra-uterine fetal transfusion made for Rh incompatibility
 (non-elective) cesarean section
 Miscarriage, if not elective or therapeutic
Mental health treatment
Eligible health services include the treatment of mental disorders provided by a hospital, psychiatric
hospital, residential treatment facility, physician or behavioral health provider as follows:
• Inpatient room and board at the semi-private room rate, and other services and supplies
related to your condition that are provided during your stay in a hospital, psychiatric hospital,
or residential treatment facility.
• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric
hospital or residential treatment facility, including:
- 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.
- Office visits to a physician or behavioral health provider such as a psychiatrist, psychologist,
social worker, or licensed professional counselor.
Substance related disorders treatment
Eligible health services include the treatment of substance abuse provided by a hospital, psychiatric
hospital, residential treatment facility, physician or behavioral health provider as follows:
• Inpatient room and board at the semi-private room rate and other services and supplies that
are provided during your stay in a hospital, psychiatric hospital or residential treatment
facility. Treatment of substance abuse in a general medical hospital is only covered if you are
admitted to the hospital’s separate substance abuse section or unit, unless you are admitted for
the treatment of medical complications of substance abuse.
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!s used here, “medical complications” include, but are not limited to, detoxification, electrolyte
imbalances, malnutrition, cirrhosis of the liver, delirium tremens and hepatitis.
• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric
hospital or residential treatment facility, including:
- Partial hospitalization treatment provided in a facility or program for treatment of
substance abuse provided under the direction of a physician.
- Intensive Outpatient Program provided in a facility or program for treatment of substance
abuse provided under the direction of a physician.
- Ambulatory detoxification which are outpatient services that monitor withdrawal from
alcohol or other substance abuse, including administration of medications.
- Office visits to a physician or behavioral health provider such as a psychiatrist, psychologist,
social worker, or licensed professional counselor.
Important note:
Please refer to the Physicians and other health professionals section for information about eligible
health services for telemedicine consultations.
Reconstructive breast surgery
Mastectomy
Eligible health services include reconstructive surgery following a mastectomy as a result of cancer in
the following circumstances:
• Your surgery reconstructs the breast where a necessary mastectomy was performed, such as an
implant and areolar reconstruction. It also includes surgery on a healthy breast to make it
symmetrical with the reconstructed breast and prostheses and physical therapy to treat
complications of the mastectomy, including lymphedema. Without regard to the lapse of time
between the mastectomy and the reconstruction, creation of a new breast mound, and creation
of the nipple/areolar complex is included.
 Includes augmentation, reduction and mastopexy of the healthy breast.
Reconstructive surgery
Eligible health services include reconstructive surgery in the following circumstances:  Your surgery corrects an accidental injury that happened no more than 24 months before your
surgery. Injuries that occur during surgical procedures or medical treatments are not
considered accidental injuries, even if unplanned or unexpected.
 Your surgery corrects a gross anatomical defect present at birth, including a congenital defect or
anomaly. The surgery will be covered if:
The defect results in severe facial disfigurement or major functional impairment of a body
part.
The purpose of the surgery is to improve function.
 Your surgery and associated services is needed to repair disfigurement resulting from an injury
 Services associated to correct disfigurement incidental to a previous surgery
 Services associated with a surgery that improves major functional impairment of a malformed
body part, unless specifically excluded elsewhere in this policy
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Transplant services
Eligible health services include organ transplant services provided by a physician and hospital only
when we precertify them.
Organ means:
 Solid organ
 Hematopoietic stem cell
 Bone marrow
Network of Transplant Specialist Facilities
The amount you will pay for covered transplant services is determined by where you get transplant
services. You can get transplant services from:
 An Institutes of Excellence™ (IOE) facility we designate to perform the transplant you need
 A Non-IOE facility
The National Medical Excellence Program® will coordinate all solid organ and bone marrow transplants.
And other specialized care you need.
Treatment of basic infertility
Eligible health services include basic infertility care, including seeing a network provider to diagnose
the underlying medical cause of infertility and any surgery needed to treat the underlying medical cause
of infertility.
7. Specific therapies and tests
Diagnostic testing
Diagnostic complex imaging services
Eligible health services include complex imaging services by a provider, including:
 Computed tomography (CT) scans
 Magnetic resonance imaging (MRI) including Magnetic resonance spectroscopy (MRS), Magnetic
resonance venography (MRV) and Magnetic resonance angiogram (MRA)
 Nuclear medicine imaging including Positron emission tomography (PET) scans
 Other outpatient diagnostic imaging service where the billed charge exceeds $500­
Complex imaging for preoperative testing is covered under this benefit.
Outpatient diagnostic lab work and radiological services
Eligible health services include diagnostic radiological services (other than diagnostic complex
imaging), lab services, and pathology and other tests, but only when you get them from a
licensed radiological facility or lab. Eligible health services include charges for lab services, and
pathology and other tests provided to diagnose an illness or injury. You must have definite
symptoms that start, maintain or change a plan of treatment prescribed by a physician.
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Bone mass measurement
Eligible health services include bone mass measurement testing for the diagnosis and evaluation of
osteoporosis or low bone mass if you are a qualified individual. You are a qualified individual if you:
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are estrogen-deficient and at clinical risk of osteoporosis or low bone mass
have radiographic osteopenia anywhere in the skeleton
are receiving long-term glucocorticoid (steroid) therapy
have primary hyperparathyroidism
are being monitored to assess the response to commonly accepted osteoporosis drug therapies
have a history of low-trauma fractures
have other conditions or
are on medical therapies known to cause osteoporosis or low bone mass.
“one mass measurement” means a scientifically proven radiologic, radioisotopic, or other procedure
performed to identify bone mass or detect bone loss.
At least 23 months will have elapsed since your last bone mass measurement was performed, except
when a more frequent follow-up is medically necessary. Conditions under which more frequent bone
mass measurement testing may be medically necessary include, but are not limited to:
 your monitoring while on glucocorticoid therapy for more than three months; or
 determining the effectiveness of an additional treatment regimen while proven to have low
bone mass so long as the bone mass measurement is performed 12 to 18 months from the start
date of the additional regimen.
Colorectal screening
Eligible health services include colorectal cancer examinations and laboratory tests, in accordance with
the most recently published American Cancer Society guidelines or guidelines adopted by the North
Carolina Advisory Committee on Cancer Coordination and Control. It covers any nonsymptomatic
member who is:
 at least 50 years of age; or
 less than 50 and at high risk for colorectal cancer according to the most screening guidelines of
the American Cancer Society or guidelines adopted by the North Carolina Advisory Committee
on Cancer Coordination and Control.
Chemotherapy Eligible health services for chemotherapy depends on where treatment is received. In most cases,
chemotherapy is covered as outpatient care. However, your hospital benefit covers the initial dose of chemotherapy after a cancer diagnosis during a hospital stay. Newborn hearing screening
Eligible health services includes physiological screening in each ear for the presence of permanent
hearing loss when ordered by the attending physician, for newborns.
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Outpatient infusion therapy
Eligible health services include infusion therapy you receive in an outpatient setting including but not
limited to:
 A free-standing outpatient facility
 The outpatient department of a hospital
 A physician in his/her office
 A home care provider in your home
You can access the list of preferred infusion locations by contacting Member Services by logging onto
your my.aetna.com secure member website at www.aetna.com or calling the number on the back of
your ID card.
Infusion therapy is the parenteral (i.e., intravenous) administration of prescribed medications or
solutions.
Certain infused medications may be covered under the outpatient prescription drug section. You can
access the list of specialty care prescription drugs by contacting Member Services or by logging onto
your my.aetna.com secure member website at www.aetna.com or calling the number on the back of
your ID card to determine if coverage is under the outpatient prescription drug section or the medical
section.
When Infusion therapy services and supplies are provided in your home, they will not count toward any
applicable home health care maximums.
Specialty care prescription drugs
Eligible health services include specialty care prescription drugs when they are:
 Purchased by your provider, and
 Injected or infused by your provider in an outpatient setting such as:
- A free-standing outpatient facility
- The outpatient department of a hospital
- A physician in his/her office
- A home care provider in your home
 And, listed on our specialty care prescription drug list as covered under this policy.
You can access the list of specialty care prescription drugs by contacting Member Services by logging
onto your my.aetna.com secure member website at www.aetna.com or calling the number on the back
of your ID card. to determine if coverage is under the outpatient prescription drug section or the
medical section.
Certain injected and infused medications may be covered under the outpatient prescription drug
section. You can access the list of specialty care prescription drugs by contacting Member Services or
by logging onto your my.aetna.com secure member website at www.aetna.com or calling the number
on the back of your ID card to determine if coverage is under the outpatient prescription drug section.
When injectable or infused services and supplies are provided in your home, they will not count toward
any applicable home health care maximums.
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Outpatient radiation therapy
Eligible health services include the following radiology services provided by a health professional:
 Radiological services
 Gamma ray
 Accelerated particles
 Mesons
 Neutrons
 Radium
 Radioactive isotopes
Short-term cardiac and pulmonary rehabilitation services
Eligible health services include the cardiac and pulmonary rehabilitation services listed below.
Cardiac rehabilitation
Eligible health services include cardiac rehabilitation services you receive at a hospital, skilled nursing
facility or physician’s office, but only if those services are part of a treatment policy determined by your risk level and ordered by your physician. .
Pulmonary rehabilitation
Eligible health services include pulmonary rehabilitation services as part your inpatient hospital stay if it is part of a treatment plan ordered by your physician.
A course of outpatient pulmonary rehabilitation may also be eligible for coverage if it is performed at a hospital, skilled nursing facility, or physician’s office, is used to treat reversible pulmonary disease states, and is part of a treatment policy ordered by your physician.
Short-term rehabilitation services Eligible health services include short-term rehabilitation services your physician prescribes. The services have to be performed by:
 A licensed or certified physical, occupational or speech therapist  A hospital, skilled nursing facility, or hospice facility
 A home health care agency
 A physician
Short-term rehabilitation services have to follow a specific treatment plan, ordered by your physician,
that:
 Details the treatment, and specifies frequency and duration, and
 Provides for ongoing reviews and is renewed only if continued therapy is appropriate.
 Allows therapy services, provided in your home, if you are homebound
Outpatient cognitive rehabilitation, physical, occupational, and speech therapy
Eligible health services include:
 Physical therapy, but only if it is expected to significantly improve or restore physical functions
lost as a result of an acute illness, injury or surgical procedure.
 Occupational therapy (except for vocational rehabilitation or employment counseling), but only
if it is expected to:
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Significantly improve, develop or restore physical functions you lost as a result of an acute
illness, injury or surgical procedure, or
- Relearn skills to significantly improve your independence in the activities of daily living.
- Occupational therapy does not include educational therapy.
 Speech therapy, but only if it is expected to:
- Significantly improve or restore the speech function or correct a speech impairment as a
result of an acute illness, injury or surgical procedure, or
- Improve delays in speech function development caused by a gross anatomical defect
present at birth.
Speech function is the ability to express thoughts, speak words and form sentences. Speech impairment
is difficulty with expressing one’s thoughts with spoken words.
 Cognitive rehabilitation associated with physical rehabilitation, but only when:
- Your cognitive deficits are caused by neurologic impairment due to trauma, stroke, or
encephalopathy and
- The therapy is coordinated with us as part of a treatment policy intended to restore
previous cognitive function.
Spinal manipulation
Eligible health services include spinal manipulation to correct a muscular or skeletal problem. Your provider must establish or approve a treatment plan that details the treatment, and specifies frequency and duration.
Habilitation therapy services
Eligible health services include habilitation therapy services your physician prescribes. The services have
to be performed by:
 A licensed or certified physical, occupational or speech therapist  A hospital, skilled nursing facility, or hospice facility
 A home health care agency
 A physician
Habilitation therapy services have to follow a specific treatment plan, ordered by your physician, that:
 Details the treatment, and specifies frequency and duration, and
 Provides for ongoing reviews and is renewed only if continued therapy is appropriate.
 Allows therapy services, provided in your home, if you are homebound.
Outpatient physical, occupational, and speech therapy
Eligible health services include:
 Physical therapy, if it is expected to develop any impaired function.
 Occupational therapy (except for vocational rehabilitation or employment counseling), if it is
expected to:
- Develop any impaired function, or
- Relearn skills to significantly develop your independence in the activities of daily living
 Speech therapy is covered provided the therapy is expected to:
- Develop speech function as a result of delayed development
(Speech function is the ability to express thoughts, speak words and form sentences).
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8. Other services
Acupuncture Benefit
Eligible health services include charges made for acupuncture services provided by a physician, if the
service is performed as a form of anesthesia in connection with covered surgical procedure.
Administration of Blood and Blood Products
Eligible health services include the administration of blood and blood products but not the cost of blood
or blood products.
Ambulance service
Eligible health services include transport by professional ground ambulance services:
 To the first hospital to provide emergency services.
 From one hospital to another hospital if the first hospital cannot provide the emergency
services you need.
 From hospital to your home or to another facility if an ambulance is the only safe way to
transport you.
 From your home to a hospital if an ambulance is the only safe way to transport you. Transport is
limited to 100 miles.
 When during a covered inpatient stay at a Hospital, Skilled Nursing Facility or acute
rehabilitation Hospital, an Ambulance is required to safely and adequately transport you to or
from inpatient or outpatient Medically Necessary treatment.
Your policy also covers transportation to a hospital by professional air or water ambulance when:
 Professional ground ambulance transportation is not available.
 Your condition is unstable, and requires medical supervision and rapid transport.
 You are travelling from one hospital to another and
- The first hospital cannot provide the emergency medical services you need, and
- The two conditions above are met.
Bariatric Surgery
Eligible health services include the treatment of morbid obesity and include one bariatric surgical
procedure including related outpatient services, within a two-year period, beginning with the date of the first bariatric surgical procedure, unless a multi-stage procedure is planned.
Clinical trial therapies (experimental or investigational)
Eligible health services include experimental or investigational drugs, devices, treatments or procedures from a provider under an “approved clinical trial” only when you have cancer or a terminal
illness and all of the following conditions are met:
 Standard therapies have not been effective or are not appropriate.
 We determine based on published, peer-reviewed scientific evidence that you may benefit from
the treatment.
An "approved clinical trial" is a clinical trial that meets all of these criteria:
 The FDA has approved the drug, device, treatment, or procedure to be investigated or has
granted it investigational new drug (IND) or group c/treatment IND status. This requirement
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does not apply to procedures and treatments that do not require FDA approval.
The clinical trial has been approved by an Institutional Review Board that will oversee the
investigation.
The clinical trial is sponsored by the National Cancer Institute (NCI) or similar federal
organization.
The trial conforms to standards of the NCI or other, applicable federal organization.
The clinical trial takes place at an NCI-designated cancer center or takes place at more than one
institution.
You are treated in accordance with the protocols of that study.
Clinical trials (routine patient costs)
Eligible health services include "routine patient costs" furnished to you in connection with participation
in an "approved phase I, phase II, phase III, or phase IV clinical trial” as a “qualified individual" for cancer
or other life-threatening disease or condition, as those terms are defined in the federal Public Health Service Act, Section 2709. Coverage is limited to benefits for routine patient services provided within the network.
Durable medical equipment (DME)
Eligible health services include the expense of renting or buying DME and accessories you need to
operate the item from a DME supplier. Your policy will cover either buying or renting the item, depending on which we think is more cost efficient. If you purchase DME, that purchase is only eligible for coverage if you need it for long-term use.
Instruction and appropriate services required for the member to properly use the item, such as attachment or insertion, is also covered upon precertification by us. Coverage includes:
 One item of DME for the same or similar purpose.
 Repairing DME due to normal wear and tear. It does not cover repairs needed because of
misuse or abuse.
 A new DME item you need because your physical condition has changed. It also covers buying a
new DME item to replace one that was damaged due to normal wear and tear, if it would be
cheaper than repairing it or renting a similar item.
Your policy only covers the same type of DME that Medicare covers. But there are some DME items
Medicare covers that your policy does not. We list examples of those in the exceptions section.
All maintenance and repairs that result from a misuse or abuse are your responsibility.
Hearing aids and exams
Eligible health services include hearing exams, prescribed hearing aids and hearing aid expenses as
follows:
 Charges for an audiometric hearing exam and evaluation for a hearing aid prescription
performed by:
- A certified otolaryngologist or otologist
- A legal qualified audiologist or an audiologist with a certificate of Clinical Competence in
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Audiology from the American Speech and Hearing Association and who performs the exam
at the written direction of a legally qualified otolaryngologist or otologist
Charges for electronic hearing aids, installed according to a written Prescription during a
covered hearing exam
Charges related to necessary services to access, select and adjust or fit a hearing aid
One hearing aid per hearing-impaired ear, and replacement hearing aids when alterations to an
existing hearing aid are not adequate. Limited to once every 36 months.
Lymphedema
Eligible health services include the diagnosis, evaluation, and treatment of lymphedema. Your plan will
cover:
 Medically necessary treatment provided by a licensed occupational or physical therapist or
licensed nurse experienced in providing this treatment, or other licensed health care
professional who treatment of lymphedema is within their professional scope of practice.
 Equipment
 Supplies
 Complex decongestive therapy
 Self-management training and education by a licensed health care professional
 Gradient compression garments:
- Require a prescription
- Are custom-fit for you
- Do not include disposable medical supplies such as over-the-counter compression or elastic
knee-high or other stocking products
Nutritional supplements
Eligible health services include treatment for formula and low protein modified food products ordered
by a physician for the treatment of phenylketonuria or an inherited disease of amino and organic acids.
For purposes of this benefit, “low protein modified food product” means foods that are specifically
formulated to have less than one gram of protein per serving and are intended to be used under the
direction of a physician for the dietary treatment of any inherited metabolic disease. Low protein
modified food products do not include foods that are naturally low in protein.
Prosthetic devices
Eligible health services include the initial provision and subsequent replacement of a prosthetic device
that your physician orders and administers. But we cover it only if we approve the device in advance.
Prosthetic device means:
 A device that temporarily or permanently replaces all or part of an external body part lost or
impaired as a result of illness or injury or congenital defects.
Coverage includes:
 Repairing or replacing the original device you outgrow or that is no longer appropriate because
your physical condition changed
 Replacements required by ordinary wear and tear or damage
 Instruction and other services (such as attachment or insertion) so you can properly use the
device
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Vision care
Pediatric vision care
Routine vision exams
Eligible health services include a routine vision exam provided by an ophthalmologist or optometrist.
The exam will include refraction and glaucoma testing.
This benefit is subject to an age limit as shown on the schedule of benefits.
Vision care services and supplies
Eligible health services include:
 Office visits to an ophthalmologist, optometrist or optician related to the fitting of prescription
contact lenses
 Eyeglass frames, prescription lenses or prescription contact lenses
 Non-conventional prescription contact lenses that are required to correct visual acuity to 20/40
or better in the better eye and that correction cannot be obtained with conventional lenses
 Aphakic prescription lenses prescribed after cataract surgery has been performed
 Low vision services
This benefit is subject to an age limit as shown on the schedule of benefits.
In any one calendar year this benefit will cover either prescription lenses for eyeglass frames or
prescription contact lenses, but not both.
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9. Outpatient prescription contraceptive drugs and devices, Preventive care drugs
and supplements, Risk reducing breast cancer prescription drugs, Tobacco
cessation prescription and over-the-counter drugs
Preventive Contraceptives
For females who are able to reproduce, your policy covers only the services and supplies that the
U.S. Food and Drug Administration (FDA) has approved to prevent pregnancy.
Eligible health services include the following for contraceptive use when prescribed by a prescriber and
the prescription is submitted to the pharmacist for processing:
 Female contraceptives that are FDA-approved generic prescription drugs:
- Oral drugs - Injectable drugs
- Transdermal contraceptive patches
 FDA-approved contraceptive vaginal rings that are generic. To the extent generic vaginal rings
are not available, brand name vaginal rings will be covered.
 FDA-approved female contraceptive devices that are generic devices and brand name devices.
Eligible health services includes the related services and supplies needed to administer the
device. To the extent generic contraceptive devices are not available, brand name
contraceptive devices will be covered.
 FDA approved female generic emergency contraceptives. To the extent one of the emergency
contraceptive methods are not available as generic, a brand name emergency contraceptive will
be covered.
 Other FDA approved female generic over-the-counter (OTC) contraceptives.
Important note:
You may qualify for a medical exception. If your provider documents a medical exception and
submits the exception to Aetna, certain FDA-approved brand or nonformulary contraceptives may
also be covered as preventive.
Preventive care drugs and supplements
Eligible health services include the following preventive care drugs and supplements (including over­
the-counter drugs and supplements) when prescribed by a prescriber and the prescription is submitted
to the pharmacist for processing:
• Aspirin: Available to adults.
• Oral fluoride supplements: Available to children whose primary water source is deficient in
fluoride.
• Folic acid supplements: Available to adult females planning to become pregnant or capable of
pregnancy.
• Iron supplements: Available to children without symptoms of iron deficiency. Coverage is
limited to children who are at increased risk for iron deficiency anemia.
• Vitamin D supplements: Available to adults to promote calcium absorption and bone growth in
their bodies.
Important note:
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For details on the guidelines and the current list of covered preventive care drugs and supplements,
contact Member Services by logging on to your my.aetna.com secure member website at www.
aetna.com or at the toll-free number on your ID card.
You will be reimbursed for the expense of preventive care drugs and supplements obtained from a
pharmacy. You must submit proof of loss to us to receive a claim payment.
Risk reducing breast cancer prescription drugs
Eligible health services include prescription drugs when prescribed by a prescriber and the prescription
is submitted to the pharmacist for processing for a woman who is at:
 Increased risk for breast cancer, and
 Low risk for adverse medication side effects
Important note:
For current list of the risk reducing breast cancer prescription drugs, contact Member Services by
logging on to your my.aetna.com secure member website at www. aetna.com or at the toll-free
number on your ID card.
Tobacco cessation prescription and over-the-counter drugs
Eligible health services include FDA- approved prescription drugs and over-the-counter (OTC) drugs to
help stop the use of tobacco products, when prescribed by a prescriber and the prescription is
submitted to the pharmacist for processing.
10. Outpatient prescription drugs
What you need to know about your outpatient prescription drug policy
Read this section carefully so that you know:
 How to access network pharmacies
 Eligible health services under your policy
 What outpatient prescription drugs are covered  Other services
 How you get an emergency prescription filled
 Where your schedule of benefits fits in
 What precertification requirements apply
 What your policy doesn’t cover – some eligible health service exceptions
 How you share the cost of your outpatient prescription drugs
Some prescription drugs may not be covered or coverage may be limited. This does not keep you from
getting prescription drugs that are not covered benefits. You can still fill your prescription, but you have
to pay for it yourself. For more information see the Where your schedule of benefits fits in section, and
see the schedule of benefits.
A pharmacy may refuse to fill a prescription order or refill when in the professional judgment of the
pharmacist the prescription should not be filled.
How to access network pharmacies
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How do you find a network pharmacy?
You can find a network pharmacy in two ways:
 Online: By logging onto your my.aetna.com secure member website at www.aetna.com.
 By phone: Call the toll-free Member Services the Exchange number on your member ID card.
During regular business hours, a representative can assist you. Our automated telephone
assistant can give you this information 24 hours a day.
You may go to any of our network pharmacies. If you fail to obtain your prescriptions at a network
pharmacy, your prescriptions will not be covered as eligible health services under the policy.
Pharmacies include network retail, mail order and specialty pharmacies.
What if the pharmacy you have been using leaves the network?
Sometimes a pharmacy might leave the network. If this happens, you will have to get your
prescriptions filled at another network pharmacy. You can use your provider directory or call
the toll-free Member Services the Exchange number on your member ID card to find another
network pharmacy in your area.
Eligible health services under your policy
What does your outpatient prescription drug policy cover?
Any pharmacy service that meets these three requirements:
 They are listed in the Eligible health services under your policy section.
 They are not carved out in the What your policy doesn’t cover - some eligible health service
exception section.
 They are not beyond any limits in the schedule of benefits.
Your benefits are covered when you follow the policy’s general rules.
 You need a prescription from your prescriber.
 Your drug needs to be medically necessary for your illness or injury.
 You need to show your ID card to the pharmacy when you get a prescription filled.
Your outpatient prescription drug plan includes drugs listed in the preferred drug guide (formulary).
Prescription drugs not in the preferred drug guide (formulary) are excluded unless a medical exception
is approved by us. If it is medically necessary for you to use a prescription drug not on the preferred
drug guide (formulary), you or your prescriber must request a medical exception. See the How do I get
a medical exception section. For the most up-to-date information, call the toll-free Member Services
number on your member ID card or log on to your my.aetna.com secure member website at
www.aetna.com.
Generic prescription drugs may be substituted by your pharmacist for brand-name prescription drugs.
Your out-of-pocket costs may be less if you use a generic prescription drug when available.
Eligible health services and supplies of prescription drugs may be subject to precertification, step
therapy or other Aetna requirements or limitations. Prescription drugs covered by this policy are
subject to drug and narcotics utilization review by Aetna, your prescriber and/or your network
pharmacy. This may include limiting access of prescription drugs to a specific provider or providers
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and/or excluding coverage of prescription drugs prescribed by a specific provider. Such limitation may
be enforced in the event that we identify an unusual pattern of claims for eligible health services.
What prescription drugs are covered
Your prescriber may give you a prescription in different ways, including:
 Writing out a prescription that you then take to a network pharmacy.
 Calling or e-mailing a network pharmacy to order the medication.
 Submitting your prescription electronically.
Once you receive a prescription from your prescriber, you may fill the prescription at a network retail,
mail order or specialty pharmacy.
Retail pharmacy
Generally, retail pharmacies may be used for up to a 30 day supply of prescription drugs. You should
show your ID card to the network pharmacy every time you get a prescription filled. The network
pharmacy will calculate your claim online. You will pay any cost sharing directly to the network
pharmacy.
You do not have to complete or submit claim forms. The network pharmacy will take care of claim
submission.
See the schedule of benefits for details on supply limits and cost sharing.
Mail order pharmacy
For certain kinds of prescription drugs, you can use a network 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.
Each prescription is limited to a maximum 90 supply. Prescriptions for a 30 day supply or less are not
eligible for coverage when dispensed by a network mail order pharmacy.
See the schedule of benefits for details on supply limits and cost sharing.
Specialty care pharmacy
Specialty care prescription drugs often include typically high-cost drugs that require special handling,
special storage or monitoring and include but are not limited to oral, topical, inhaled and injected routes
of administration. You can access the list of specialty care prescription drugs by contacting Member
Services by logging onto your my.aetna.com secure member website atwww.aetna.com or calling the
number on the back of your ID card.
All specialty care prescription drugs fills including the initial fill must be filled at a network specialty
pharmacy except for urgent situations.
See the schedule of benefits for details on supply limits and cost sharing.
Other services
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Diabetic supplies
Eligible health services include but are not limited to the following diabetic supplies upon prescription
by a prescriber:
• Diabetic needles and syringes
• Test strips for glucose monitoring and/or visual reading
• Diabetic test agents
• Lancets/lancing devices
• Alcohol swabs
Off-label use
U.S. Food and Drug Administration (FDA) approved prescription drugs may be covered when the offlabel use of the drug has not been approved by the FDA for your symptom(s). Eligibility for coverage is
subject to the following:
• The drug must be accepted as safe and effective to treat your symptom(s) in one of the
following standard compendia:
- American Society of Health-System Pharmacists Drug Information (AHFS Drug Information)
- Thomson Micromedex DrugDex System (DrugDex)
- Clinical Pharmacology (Gold Standard, Inc.) or
- The National Comprehensive Cancer Network (NCCN) Drug and Biologics Compendium; or
• Use for your symptom(s) has been proven as safe and effective by at least one well-designed
controlled clinical trial, (i.e., a Phase III or single center controlled trial, also known as Phase II).
Such a trial must be published in a peer reviewed medical journal known throughout the U.S.
and either:
- The dosage of a drug for your symptom(s) is equal to the dosage for the same symptom(s) as
suggested in the FDA-approved labeling or by one of the standard compendia noted above,
or
- The dosage has been proven to be safe and effective for your symptom(s) by one or more
well-designed controlled clinical trials. Such a trial must be published in a peer reviewed
medical journal.
Health care services related to off-label use of these drugs may be subject to precertification, step
therapy or other requirements or limitations.
Orally administered anti-cancer drugs, including chemotherapy drugs
Eligible health services include any drug prescribed for the treatment of cancer if it is recognized for
treatment of that indication in a standard reference compendium or recommended in the medical
literature even if the drug is not approved by the FDA for a particular indication.
Over-the-counter drugs
Eligible health services include certain over-the-counter medications, as determined under the policy, in
an equivalent prescription dosage strength for the appropriate member responsibility. Coverage of the
selected over-the-counter medications requires a prescription. You can access the list by logging onto
yourmy.aetna.com secure member website at www.aetna.com.
How you get an emergency prescription filled
You may not have access to a network pharmacy in an emergency or urgent care situation, or you may
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be traveling outside of the policy’s service area. If you must fill a prescription in either situation, we will
reimburse you as shown in the table below.
You cannot refill a prescription until 10 days of the supply has been used, except under certain
circumstances during a state of emergency or disaster. During a state of emergency or disaster, the
“refill too soon” refill procedures are waived/ The procedure shall enable covered persons or subscribers
to:
 Obtain 1 refill on a prescription if there are authorized refills remaining, or
 Fill 1 replacement prescription for one that was recently filled, as prescribed or approved by the
prescriber of the prescription that is being replaced and not contrary to the dispensing authority
of the dispensing pharmacy.
Type of pharmacy
Network pharmacy and out-of-area
network pharmacy
Out-of-network pharmacy
Your cost share
You pay the copayment.
You pay the pharmacy directly for the cost of the
prescription. Then you fill out and send a
prescription drug refund form to us, including all
itemized pharmacy receipts.
Coverage is limited to items obtained in
connection with covered emergency and out-of­
area urgent care services.
You must access a network pharmacy for urgent
care prescriptions inside the service area.
Submission of a claim doesn’t guarantee payment/
If your claim is approved, you will be reimbursed
the cost of your prescription less your network
copayment/ coinsurance.
Where your schedule of benefits fits in
You are responsible for paying your part of the cost sharing. The schedule of benefits shows any benefit
limitations and any out-of-pocket costs you are responsible for. Keep in mind that you are responsible
for costs not covered under this policy.
Your prescription drug costs are based on:
 The type of prescription you use, (generic, brand-name, preferred, non-preferred and specialty
care prescription drugs).  Where you fill your prescription, (at a network retail, mail order or specialty pharmacy).  Compounded prescriptions will be subject to a non-preferred copayment.
What precertification requirements apply
Why do some drugs need precertification?
For certain drugs, your prescriber or your pharmacist needs to get approval from us before we will agree
to cover the drug for you. This is called “precertification.” Sometimes the requirement for getting
approval in advance helps guide appropriate use of certain drugs and makes sure there is a medically
necessary need for the drug. For the most up-to-date information, call the toll-free Member Services
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number on your member ID card or log on to your my.aetna.com secure member website at
www.aetna.com.
There is another type of precertification for prescription drugs and that is step therapy. Step therapy is
a type of precertification where we require you to first try certain drugs to treat your medical condition
before we will cover another drug for that condition.
You will find the step therapy prescription drugs on the preferred drug guide (formulary). For the most
up-to-date information, call the toll-free Member Services number on your member ID card or log on to
your my.aetna.com secure member website at www.aetna.com.
How can I request a medical exception?
Sometimes you or your prescriber may seek a medical exception to get health care services for drugs
not listed on the preferred drug guide (formulary) or for brand-name, specialty care or biosimilar
prescription drugs or for which health care services are denied through precertification, step therapy.
You or your prescriber can contact us and will need to provide us with the required clinical
documentation. We will make a coverage determination within 72 hours after receipt of your request
and will notify you or your designee and your prescriber of our decision. Any waiver granted as a result
of a medical exception shall be based upon an individual, case by case determination, and will not apply
or extend to other covered persons. If approved by us, you will receive the non-preferred benefit level
and the exception will be granted for the duration of the prescription.
You, your designee or your prescriber may seek an expedited medical exception process to obtain
coverage for non-covered drugs in exigent circumstances. An exigency exists when you are suffering
from a health condition that may seriously jeopardize your life, health, or ability to regain maximum
function or when you are undergoing a current course of treatment using a non-formulary drug. You,
your designee, or your prescriber may submit a request for an expedited review for an exigency as
described by contacting Aetna's Precertification Department at 1-855-582-2025, faxing the request to
1-855-330-1716 or submitting the request in writing to CVS Health ATTN: Aetna PA 1300 E Campbell
Road Richardson, TX 75081. We will make a coverage determination within 24 hours after receipt of
your request and will notify you or your designee and your prescriber of our decision. If approved by
us the exception will be granted for the duration of the exigency.
If you are denied a medical exception based on the above processes, you may have the right to a third
party review by an independent external review organization. If our claim decision is one for which you
can seek external review, we will say that in the notice of adverse benefit determination we send you.
That notice also will describe the external review process. We will notify you, your designee or your
prescriber of the coverage determination of the external review no later than 72 hours after receiving
your request. If the medical exception is approved, coverage will be provided for the duration of the
prescription. For expedited medical exceptions in exigent circumstances, we will notify you, your
designee or your prescriber of the coverage determination no later than 24 hours after receiving your
request. If the expedited medical exception is approved, coverage will be provided for the duration of
the exigency.
Prescribing units
Some prescription drugs are subject to quantity limits. These quantity limits help your prescriber and
pharmacist check that your prescription drug is used correctly and safely. We rely on medical guidelines,
FDA-approved recommendations from drug makers and other criteria developed by us to set these
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quantity limits. The quantity limit may restrict either the amount dispensed per prescription order or
refill.
Depending on the form and packing of the product, some prescription drugs are limited to 100 units
dispensed per prescription order or refill. Drugs that are allowed to be filled with greater than 30 day
supply at a retail pharmacy are limited to 300 units dispensed per prescription order or refill.
Any prescription drug that has duration of action extending beyond one (1) month shall require the
number of copayments per prescribing unit that is equal to the anticipated duration of the
medication. For example, a single injection of a drug that is effective for three (3) months would require
three (3) copayments.
Specialty care prescription drugs may have limited access or distribution and are limited to no more
than a 30 day supply.
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What your policy doesn’t cover – some eligible health service
exceptions
We already told you about the many health care services and supplies that are eligible for coverage
under your policy in the Eligible health services under your policy section. And we told you there, that
some of those health care services and supplies have exceptions (exclusions). For example, physician
care is an eligible health service but physician care for cosmetic surgery is never covered. This is an
exception (exclusion).
In this section we tell you about the exceptions. We've grouped them to make it easier for you to find
what you want.
 Under "General exceptions" we've explained what general services and supplies are not
covered under the entire policy.
 Below the general exceptions, in “Exceptions under specific types of care,” we've explained what services and supplies are exceptions under specific types of care or conditions.
Please look under both categories to make sure you understand what exceptions may apply in your
situation.
And just a reminder, you'll find coverage limitations in the schedule of benefits.
General exceptions
Blood, blood plasma, synthetic blood, blood derivatives or substitutes
Examples of these are:
 The provision of blood to the hospital, other than blood derived clotting factors
 Any related services including processing, storage or replacement expenses
 The services of blood donors, apheresis or plasmapheresis
For autologous blood donations, only administration and processing expenses are covered.
Cosmetic services and plastic surgery
 Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or
enhance the shape or appearance of the body, except for treatment related to
congenital defects or anomalies of newborn, foster, and adopted children per state
statute. See Eligible health services under your plan Reconstructive surgery and supplies
section. Whether or not for psychological or emotional reasons.
Counseling
 Marriage, religious, family, career, social adjustment, pastoral, or financial counseling.
Court-ordered services and supplies
 Includes those court-ordered services and supplies, or those required as a condition of parole,
probation, release or as a result of any legal proceeding.
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Custodial care
Examples are:
 Routine patient care such as changing dressings, periodic turning and positioning in bed.
 Administering oral medications.
 Care of a stable tracheostomy (including intermittent suctioning).
 Care of a stable colostomy/ileostomy.
 Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings.
 Care of a bladder catheter (including emptying/changing containers and clamping tubing).
 Watching or protecting you.
 Respite care, adult (or child) day care, or convalescent care.
 Institutional care. This includes room and board for rest cures, adult day care and convalescent
care.
 Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or
preparing foods.
 Any other services that a person without medical or paramedical training could be trained to
perform.
 Any service that can be performed by a person without any medical or paramedical training.
Dental care for adults

Dental services related to:
- The care, filling, removal or replacement of teeth and treatment of injuries to or diseases of
the teeth
- Dental services related to the gums
- Apicoectomy (dental root resection)
- Orthodontics
- Root canal treatment
- Soft tissue impactions
- Bony impacted teeth
- Alveolectomy
- Augmentation and vestibuloplasty treatment of periodontal disease
- False teeth
Prosthetic restoration of dental implants
- Dental implants
This exclusion includes bone fractures, removal of tumors, and orthodontogenic cysts.
Educational services
Examples of those services are:
 Any service or supply for education, training or retraining services or testing. This
includes special education, remedial education, job training and job hardening
programs.
 Evaluation or treatment of learning disabilities, attention deficit disorder,
developmental, learning and communication disorders, behavioral disorders, (including
pervasive developmental disorders) or training, regardless of the main cause.
 Services, treatment, and educational testing and training related to behavioral (conduct)
problems, learning disabilities and delays in developing skills.
 Services such as speech therapy eligible under the Individuals with Disabilities in Education Act
(IDEA).
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Examinations
Any health or dental examinations needed:
 Because a third party requires the exam. Examples are, examinations to get or keep a
job, or examinations required under a labor agreement or other contract.
 Because a law requires it.
 To buy insurance or to get or keep a license.
 To travel.
 To go to a school, camp, or sporting event, or to join in a sport or other recreational
activity.
Experimental or investigational

Experimental or investigational drugs, devices, treatments or procedures unless otherwise
covered under clinical trial therapies (experimental or investigational) or covered under clinical
trials (routine patient costs). See the Eligible health services under your policy – Other services
section.
Facility charges
For care, services or supplies provided in:
 Rest homes
 Assisted living facilities
 Similar institutions serving as a person’s main residence or providing mainly custodial or
rest care
 Health resorts
 Spas or sanitariums
 Infirmaries at schools, colleges, or camps
Family planning services

•


Services and supplies provided for the voluntary termination of pregnancy, except when the life
of the mother is endangered by a physical disorder, physical illness, or physical injury, including
a life-endangering physical condition caused by or arising from the pregnancy itself, or when the
pregnancy is the result of an alleged act of rape or incest.
Services provided as a result of complications resulting from a voluntary sterilization procedure
and related follow-up care
The reversal of voluntary sterilization procedures, including any related follow-up care
Charges incurred for family planning services while confined as an inpatient in a Hospital or
other facility.
Foot care

Services and supplies for:
The treatment of calluses, bunions, toenails, hammertoes, fallen arches
The treatment of weak feet, chronic foot pain or conditions caused by routine
activities, such as walking, running, working or wearing shoes
Supplies (including orthopedic shoes), foot orthotics, arch supports, shoe inserts,
ankle braces, guards, protectors, creams, ointments and other equipment, devices
and supplies
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Unless specifically required for treatment or to prevent complications of diabetes.
Growth/Height care


A treatment, device, drug, service or supply to increase or decrease height or alter the
rate of growth
Surgical procedures, devices and growth hormones to stimulate growth
Except coverage will be provided for covered newborns, foster children, and adoptive
children from the moment of birth for the medically necessary care and treatment of
medically diagnosed congenital defects and birth abnormalities).
Hearing aids and exams

Hearing aid benefits are not covered except as described in the Eligible health services section,
Other services
Maintenance care

Care made up of services and supplies that maintain, rather than improve, a level of
physical or mental function, except for habilitation therapy services. See the Eligible
health services under your policy – Habilitation therapy services section.
Medical supplies – outpatient disposable
Any outpatient disposable supply or device that complies with the NC Benchmark plan.
Other primary payer

Payment for a portion of the charge that Medicare or another party is responsible for as
the primary payer.
Personal care, comfort or convenience items

Any service or supply primarily for your convenience and personal comfort or that of a
third party.
Services provided by a family member

Services provided by a spouse, domestic partner, parent, child, stepchild, brother,
sister, in-law or any household member.
Services, supplies and drugs received outside of the United States

Non-emergency medical services, outpatient prescription drugs or supplies received outside of
the United States. They are not covered even if they are covered in the United States under this
policy.
Sexual dysfunction and enhancement

Any treatment, prescription drug, service, or supply to treat sexual dysfunction,
enhance sexual performance or increase sexual desire, including:
Surgery, prescription drugs, implants, devices or preparations to correct or enhance
erectile function, enhance sensitivity, or alter the shape or appearance of a sex
organ
Sex therapy, sex counseling, marriage counseling, or other counseling or advisory
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services.

Sexual dysfunction except in the treatment due to organic disease.
Strength and performance

Services, devices and supplies such as drugs or preparations designed primarily for the purpose
of enhancing your strength, physical condition, endurance, or physical performance.
Telemedicine

Any services that are given by providers that are not contracted with Aetna as
telemedicine providers. Any services that are not provided during an internet-based
consult or via telephone.
Therapies and tests





Full body CT scans
Hair analysis
Hypnosis and hypnotherapy
massage therapy, except when used as a physical therapy modality
Sensory or auditory integration therapy
Tobacco cessation

Any treatment, drug, service or supply to stop or reduce smoking or the use of other
tobacco products or to treat or reduce nicotine addiction, dependence or cravings,
including, medications, nicotine patches and gum unless recommended by the United
States Preventive Services Task Force (USPSTF).This also includes:
Counseling, except as specifically provided in the Eligible health services under your
policy – Preventive care and wellness section
Hypnosis and other therapies
Medications, except as specifically provided in the Eligible health services under
your policy – Outpatient prescription contraceptive drugs and devices, Preventive
care drugs and supplements, Risk reducing breast cancer prescription drugs section
Nicotine patches
Gum
Vision Care



Vision care services and supplies, including:
- Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not
properly coordinated for binocular vision) and
- Laser in-situ keratomileusis (LASIK), including related procedures designed to surgically
correct refractive errors
Office visits to an ophthalmologist, optometrist or optician related to the fitting of prescription
contact lenses.
Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for
cosmetic purposes.
Work related illness or injuries

Coverage available to you under workers’ compensation or under a similar program under
local, state or federal law for any illness or injury related to employment or self-employment.
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
You may also be covered under a workers’ compensation law or similar law. If you submit proof
that you are not covered for a particular illness or injury under such law, then that illness or
injury will be considered “non-occupational” regardless of cause.
Additional exceptions for specific types of care
1. Preventive care and wellness




Services for diagnosis or treatment of a suspected or identified illness or injury
Exams given during your stay for medical care
Services not given by a physician or under his or her direction
Psychiatric, psychological, personality or emotional testing or exams
Family planning services
The following services are not covered under your policy as preventive care services:
• Services and supplies provided for the voluntary termination of pregnancy, except when the life
of the mother is endangered by a physical disorder, physical illness, or physical injury, including
a life-endangering physical condition caused by or arising from the pregnancy itself, or when the
pregnancy is the result of an alleged act of rape or incest.
• Services provided as a result of complications resulting from a voluntary sterilization procedure
and related follow-up care
• Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA
 The reversal of voluntary sterilization procedures, including any related follow-up care
 Voluntary sterilization procedures that were not billed separately by the provider or
were not the primary purpose of a confinement.
2. Physicians and other health professionals
There are no additional exceptions specific to physicians and other health professionals.
3. Hospital and other facility care
Alternatives to facility stays
Outpatient surgery and physician surgical services




The services of any other physician who helps the operating physician
A stay in a hospital (hospital stays are covered in the Eligible health services under your policy –
Hospital and other facility care section.)
A separate facility charge for surgery performed in a physician’s office
Services of another physician for the administration of a local anesthetic
Home health care and skilled behavioral health services in the home



Services of a certified or licensed social worker
Services for infusion therapy
Services provided outside of the home (such as in conjunction with school, vacation, work or
recreational activities)
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


Transportation
Services or supplies provided to a minor or dependent adult when a family member or caregiver
is not present
Services are not for Applied Behavior Analysis
Hospice care




Funeral arrangements
Pastoral counseling
Financial or legal counseling. This includes estate planning and the drafting of a will
Homemaker or caretaker services. These are services which are not solely related to your care
and may include:
Sitter or companion services for either you or other family members
Transportation
Maintenance of the house
Private duty nursing (See home health care in the Eligible health services under your policy
and Outpatient and inpatient skilled nursing care sections regarding coverage of nursing
services).
 Covered benefits will not include private duty nursing for any shifts during a calendar year in
excess of the Private duty nursing care Maximum Shifts. Each period of private duty nursing of
up to 8 hours will be deemed to be one private duty nursing shift.
4. Emergency services and urgent care


Non-emergency care in a hospital emergency room facility
Non-urgent care in an urgent care facility (at a non-hospital freestanding facility)
5. Pediatric dental care






Charges made for the following are not covered except to the extent listed under the Eligible
health services under your policy – Specific conditions section.
Acupuncture, acupressure and acupuncture therapy, except as provided in the Eligible health
services under your policy – Specific conditions section.
Any charges in excess of the benefit, dollar, day, visit, or supply limits stated in the policy
Any instruction for diet, plaque control and oral hygiene
Charges submitted for services
- By an unlicensed hospital, physician or other provider; or
- By a licensed hospital, physician or other provider that are not within the scope of the
provider’s license
Charges submitted for services that are not rendered, or not rendered to a person not eligible
for coverage under the plan
Cosmetic services and supplies including plastic surgery, reconstructive surgery, cosmetic
surgery, personalization or characterization of dentures or other services and supplies which
improve alter or enhance appearance, augmentation and vestibuloplasty, and other substance
to protect, clean, whiten bleach or alter the appearance of teeth; whether or not for
psychological or emotional reasons; except to the extent coverage is specifically provided in the
Eligible health services under your policy – Specific conditions section. Facings on molar crowns
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













and pontics will always be considered cosmetic.
Court ordered services, including those required as a condition of parole or release.
Crown, inlays, onlays, and veneers unless:
- It is treatment for decay or traumatic injury and teeth cannot be restored with a filling
material, or
- The tooth is an abutment to a covered partial denture or fixed bridge
Dental Examinations that are:
- Required by a third party, including examinations and treatments required to obtain or
maintain employment, or which an employer is required to provide under a labor
agreement
- Required by any law of a government, securing insurance or school admissions, or
professional or other licenses
- Required to travel, attend a school, camp, or sporting event or participate in a sport or other
recreational activity
- Any special medical reports not directly related to treatment except when provided as part
of a covered service
Dental implants and removal of implants (that are determined not to be medically necessary) ,
braces, mouth guards, and other devices to protect, replace or reposition teeth
Dental services and supplies that are covered in whole or in part under any other part of this
plan
Dentures, crowns, inlays, onlays, bridges, or other appliances or services used:
For splinting
To alter vertical dimension
To restore occlusion, or
For correcting attrition, abrasion, abfraction or erosion
Experimental or investigational drugs, devices, treatments or procedures, except as described
in Eligible health services under your policy – Specific conditions section
General anesthesia and intravenous sedation, unless specifically covered and only when done in
connection with another medically necessary eligible health service
Medicare: payment for that portion of the charge that Medicare is the primary payer
Miscellaneous charges for services or supplies including:
- Annual or other charges to be in a physician’s practice
- Charges to have preferred access to a physician’s services such as boutique or concierge
physician practices
- Cancelled or missed appointment charges or charges to complete claim forms
Charges the recipient has no legal obligation to pay; or the charges would not be made if the
recipient did not have coverage (to the extent exclusion is permitted by law) including:
- Care in charitable institutions
- Care for conditions related to current or previous military service
- Care while in the custody of a governmental authority
Any care a public hospital or other facility is required to provide
Non-medically necessary services, including but not limited to:
- Treatments, services, prescription drugs and supplies which are not medically necessary for
the diagnosis and treatment of illness, injury, restoration of physiological functions, or
covered preventive services. This applies even if they are prescribed, recommended or
approved by your physician or dentist
Orthodontic treatment except as covered in the Orthodontic Treatment Rule section of the
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policy
 Pontics, crowns, cast or processed restorations made with high noble metals (gold)
 Prescribed drugs; pre-medication; or analgesia
 Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of
appliances that have been damaged due to abuse, misuse or neglect and for an extra set of
dentures
 Replacement of teeth beyond the normal complement of 32
 Routine dental exams and other preventive services and supplies, except as specifically provided
in the Eligible health services under your policy – Other services section
 Services and supplies done where there is no evidence of pathology, dysfunction, or disease
other than covered preventive services.
 Services and supplies provided for your personal comfort or convenience, or the convenience of
any other person, including a provider.
 Services and supplies provided in connection with treatment or care that is not covered under
the policy.
 Services rendered before the effective date or after the termination of coverage.
 Space maintainers except when needed to preserve space resulting from the premature loss of
deciduous teeth
 Surgical removal of impacted wisdom teeth only for orthodontic reasons
Treatment by other than a dentist or dental provider that is legally qualified to furnish dental services
or supplies.
6. Specific conditions
Autism spectrum disorder

Early intensive behavioral interventions (including Applied Behavioral Analysis, Denver,
LEAP, TEACCH, Rutgers, floor time, Lovaas and similar programs) and other intensive
educational interventions.
Artificial organs

Any device that would perform the function of a body organ.
Family planning services - other



Voluntary termination of pregnancy
Reversal of voluntary sterilization procedures, for males and females, including related followup care
Family planning services received while confined as an inpatient in a hospital or other
facility.
Mental health treatment


Care for conditions that state or local laws require to be treated in a public facility, including but
not limited to, mental illness commitments.
Mental health services for the following categories (or equivalent terms as listed in the most
recent version of the International Classification of Diseases (ICD)):
- Dementias and amnesias without behavioral disturbances
- Sexual deviations and disorders except for gender identity disorders
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-
Tobacco use disorders
Specific disorders of sleep
Antisocial or dissocial personality disorder
Pathological gambling, kleptomania, pyromania
Specific delays in development (learning disorders, academic underachievement)
Intellectual disability
Wilderness Treatment Program or any such related or similar program
School and/or education service.
Substance related disorders treatment
•
Except as provided in the Eligible health services under your policy – Substance related disorders
treatment section alcoholism or drug abuse rehabilitation treatment on an inpatient or
outpatient basis.
Bariatric surgery

Except as provided in the Eligible health services under your policy – Bariatric surgery
section.
Transplant services





Services and supplies furnished to a donor when the recipient is not a covered person
Harvesting and storage of organs, without intending to use them for immediate
transplanation for your existing illness
Outpatient drugs including bio-medicals and immunosuppressants not expressly related
to an outpatient transplant occurrence
Home infusion therapy
Harvesting and/or storage of bone marrow, or hematopoietic stem cells without
intending to use them for transplantation, for an existing illness
Treatment of infertility

•
•
•
•
Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH
agonists.
All charges associated with:
- Surrogacy for you or the surrogate. A surrogate is a female carrying her own genetically
related child where the child is conceived with the intention of turning the child over to be
raised by others, including the biological father.
- Cryopreservation of eggs, embryos, or sperm.
- Storage of eggs, embryos, or sperm.
- Thawing of cryopreserved eggs, embryos or sperm.
- The care of the donor in a donor egg cycle. This includes, but is not limited to, any payments
to the donor, donor screening fees, fees for lab tests, and any charges associated with care
of the donor required for donor egg retrievals or transfers.
- The use of a gestational carrier for the female acting as the gestational carrier. A gestational
carrier is a female carrying an embryo to which she is not genetically related.
- Comprehensives infertility services and ART services that are not medically necessary.
Home ovulation prediction kits or home pregnancy tests.
The purchase of donor embryos, donor oocytes, or donor sperm.
Reversal of voluntary sterilizations, including follow-up care.
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•


Any charges associated with obtaining sperm for ART services.
Ovulation induction with menotropins, Intrauterine insemination and any related services,
products or procedures.
In vitro fertilization (IVF), Zygote intrafallopian transfer (ZIFT), Gamete intrafallopian
transfer (GIFT), Cryopreserved embryo transfers and any related services, products or
procedures (such as Intracytoplasmic sperm injection (ICSI) or ovum microsurgery).
7. Specific therapies and tests
Acupuncture acupressure and acupuncture therapy, except as provided in the covered
benefits section.
Outpatient infusion therapy, except as covered in the eligible health services section





Specialty care prescription drugs and medicines.
Drugs that are included on the list of specialty care prescription drugs as covered under your
outpatient prescription drug policy.
Enteral nutrition
Blood transfusions and blood products
Dialysis
Specialty care prescription drugs

Specialty care prescription drugs and medicines provided through a third party vendor.
Drugs that are included on the list of specialty care prescription drugs as covered under
your outpatient prescription drug plan.
Short-term rehabilitation services
Outpatient cognitive rehabilitation, physical, occupational and speech therapy
 Except for physical therapy, occupational therapy or speech therapy provided for the treatment
of Autism Spectrum Disorder, therapies to treat delays in development and/or chronic
conditions. Examples of non-covered diagnoses that are considered both developmental and/or
chronic in nature are:
Autism Spectrum Disorder
Down syndrome
- Cerebral palsy
 Any service unless provided in accordance with a specific treatment plan.
 Services you get from a home health care agency.
 Services provided by a physician, or treatment covered as part of the spinal manipulation
benefit. This applies whether or not benefits have been paid under the spinal manipulation
section.
 Services not given by a physician (or under the direct supervision of a physician), physical,
occupational or speech therapist.
 Services for the treatment of delays in development, including speech development, unless as a
result of a gross anatomical defect present at birth.
Habilitation therapy services
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Physical, occupational and speech therapy
 Except for physical therapy, occupational therapy or speech therapy provided for the treatment
of Autism Spectrum Disorder, therapies to treat delays in development and/or chronic
conditions. Examples of non-covered diagnoses that are considered both developmental and/or
chronic in nature are:
- Pervasive developmental disorders
- Down syndrome
 Any service unless provided in accordance with a specific treatment plan.
 Services you get from a home health care agency.
 Services not given by a physician (or under the direct supervision of a physician), physical,
occupational or speech therapist.
 Services for the treatment of delays in development, including speech development, unless as a
result of a gross anatomical defect present at birth.
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8. Other services
Ambulance services


Ambulance services, for routine transportation to receive outpatient or inpatient
services.
Fixed wing air ambulance from an out-of-network provider
Clinical trial therapies (experimental or investigational)

Your policy does not cover clinical trial therapies (experimental or investigational), except
as described in the Eligible health services under your policy - Clinical trial therapies
(experimental or investigational) section.
Clinical trial therapies (routine patient costs)
•
•
•
Services and supplies related to data collection and record-keeping that is solely needed due
to the clinical trial (i.e. protocol-induced costs)
Services and supplies provided by the trial sponsor without charge to you
The experimental intervention itself (except medically necessary Category B investigational
devices and promising experimental and investigational interventions for terminal illnesses
in certain clinical trials in accordance with Aetna’s claim policies).
Durable medical equipment (DME)
Examples of these items are:
 Whirlpools
 Portable whirlpool pumps
 Sauna baths
 Message devices
 Over bed tables
 Elevators
 Communication aids
 Vision aids
 Telephone alert systems
Nutritional supplements

Any food item, including infant formulas, nutritional supplements, vitamins, plus
prescription vitamins, medical foods and other nutritional items, even if it is the sole
source of nutrition, except as covered in the Eligible health services under your
policy – Other services section.
Prosthetic devices



Services covered under any other benefit
Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet,
unless required for the treatment of or to prevent complications of diabetes, or if the
orthopedic shoe is an integral part of a covered leg brace
Trusses, corsets, and other support items
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

Repair and replacement due to loss, misuse, abuse or theft
Orthotic devices except for correction of POSITIONAL PLAGIOCEPHALY, including dynamic
orthotic cranioplasty (DOC) bands and soft helmets
Spinal manipulation


Care in connection with the detection and correction by manual or mechanical
means of structural imbalance, distortion or dislocation in the human body.
Other physical treatment of any condition caused by or related to
neuromusculoskeletal disorders of the spine, including manipulation of the spine.
Vision Care
Pediatric vision care



Office visits to an ophthalmologist, optometrist or optician related to the fitting of
prescription contact lenses
Eyeglass frames, prescription lenses and prescription contact lenses that are not identified
as preferred by a vision provider
Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for
cosmetic purposes
Vision care services and supplies
Your policy does not cover vision care services and supplies, except as described in the Eligible
health services under your policy – Other services section.
 Special supplies such as non-prescription sunglasses
 Special vision procedures, such as orthoptics or vision therapy
 Eye exams during your stay in a hospital or other facility for health care
 Eye exams for contact lenses or their fitting
 Eyeglasses or duplicate or spare eyeglasses or lenses or frames
 Replacement of lenses or frames that are lost or stolen or broken
 Acuity tests
 Eye surgery for the correction of vision, including radial keratotomy, LASIK and
similar procedures
 Services to treat errors of refraction
9. Outpatient prescription contraceptive drugs and devices, Preventive
care drugs and supplements, Risk reducing breast cancer
prescription drugs, and Tobacco Cessation prescription and OTC
drugs
Except as described in the Eligible health services under your plan – Outpatient prescription
contraceptives drugs and devices, Preventive care drugs and supplements, Risk reducing breast
cancer and Tobacco cessation prescription and over-the-counter section, your plan does not cover as
preventive care:


Oral drugs that are brand-name prescription drugs and biosimilar prescription drugs.
Injectable drugs that are brand-name prescription drugs and biosimilar prescription drugs.
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



Vaginal rings that are brand-name prescription drugs and biosimilar prescription drugs.
Transdermal contraceptive patches that are brand-name prescription drugs and biosimilar
prescription drugs.
FDA-approved female brand name and biosimilar emergency contraceptives and brand
name over-the-counter (OTC) emergency contraceptives.
Other FDA-approved female and male brand name over-the-counter (OTC) contraceptives.
10. Outpatient prescription drugs
Abortion drugs
Allergy sera and extracts
Any services related to the dispensing, injection or application of a drug
Biological sera
Brand-name prescription drugs and devices

Brand-name prescription drugs and devices when a generic prescription drug equivalent,
biosimilar prescription drug or generic prescription drug alternative is available, unless
otherwise covered by medical exception.
Cosmetic drugs

Cosmetic drugs, medications or preparations used for cosmetic purposes or to
promote hair growth and removal, including but not limited to health and beauty
aids, chemical peels, dermabrasion, treatments, bleaching, creams, ointments or
other treatments or supplies to remove tattoos, scars or to alter the appearance or
texture of the skin.
Devices and appliances that do not have a National Drug Code (NDC)
Dietary supplements including medical foods
Drugs or medications





Administered or entirely consumed at the time and place it is prescribed or dispensed.
Which do not, by federal or state law, require a prescription order (i.e. over-the-counter
(OTC) drugs), even if a prescription is written. See the Eligible health services under your
plan – Outpatient prescription contraceptive drugs and devices and Preventive care drugs
and supplements section.
That includes the same active ingredient or a modified version of an active ingredient.
That is therapeutically equivalent or therapeutically alternative to a covered prescription
drug (unless a medical exception is approved)
That is therapeutically equivalent or therapeutically alternative to an over-the-counter
(OTC) product (unless a medical exception is approved).
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






Provided by, or while the person is an inpatient in, any healthcare facility, or for any drugs
provided on an outpatient basis in any such institution to the extent benefits are payable for
it.
Recently approved by the U.S. Food and Drug Administration (FDA), but which have not yet
been reviewed by Aetna's Pharmacy and Therapeutics Committee
That include methadone maintenance medications used for drug detoxification
That includes vitamins and minerals, both over-the counter (OTC) and legend, except legend
pre-natal vitamins for pregnant or nursing females, liquid or chewable legend pediatric
vitamins for children under age 13, and potassium supplements to prevent/treat low
potassium and legend vitamins that are for the treatment of renal disease,
hyperparathyroidism or other covered conditions with prior approval from us unless
recommended by the United States Preventive Services Task Force (USPSTF)
For which the cost is recoverable under any federal, state, or government agency or any
medication for which there is no charge made to the recipient.
That are used for the treatment of sexual dysfunction/enhancement
That are drugs or growth hormones used to stimulate growth and treat idiopathic short
stature unless there is evidence that the member meets one or more clinical criteria
detailed in our precertification and clinical policies.
Duplicative drug therapy (e.g. two antihistamine drugs)
Genetic care

Any treatment, device, drug, service or supply to alter the body’s genes, genetic
make-up, or the expression of the body’s genes except for the correction of
congenital birth defects.
Immunizations related to travel or work
Immunization or immunological agents
Implantable drugs and associated devices See the Eligible health services under your policy –
Outpatient prescription contraceptive drugs and devices and Preventive care drugs and supplements
section.
Infertility

Injectable prescription drugs used primarily for the treatment of infertility.
Injectables
•
•
•
•
•
Any charges for the administration or injection of prescription drugs or injectable insulin
and other injectable drugs covered by us
Injectable drugs dispensed by out-of-network pharmacies
Needles and syringes, including but not limited to diabetic needles and syringes
Injectable drugs, unless dispensed through the network specialty pharmacy
For any refill of a designated specialty care prescription drug not dispensed by or obtained
through the network specialty pharmacy. (An updated copy of the list of specialty care
prescription drugs designated by this plan to be refilled by or obtained through the network
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specialty pharmacy is available upon request or may be accessed by logging onto your
my.aetna.com secure member website at www.aetna.com.)
Insulin pumps or tubing or other ancillary equipment and supplies for insulin pumps
(except in the treatment of diabetes) see the Eligible health services under your policy – Diabetic
equipment, supplies and education section.
Plan approved blood glucose meters, asthma holding chambers and peak flow meters are eligible
health services.
Prescribed contraceptive diaphragms are limited to two (2) per calendar year.
Prescription drugs:
 Dispensed by other than a network retail, mail order and specialty pharmacies
 Dispensed by an out-of-network mail order pharmacy, except in a medical emergency or
urgent care situation.
 For which there is an over-the-counter (OTC) product which has the same active ingredient
and strength even if a prescription is written.
 Filled prior to the effective date or after the termination date of coverage under this policy.
 Dispensed by a mail order pharmacy that include prescription drugs that cannot be shipped
by mail due to state or federal laws or regulations, or when the plan considers shipment
through the mail to be unsafe. Examples of these types of drugs include, but are not limited
to, narcotics, amphetamines, DEA controlled substances and anticoagulants.
 That include an active metabolite, stereoisomer, prodrug (precursor) or altered formulation
of another drug and is no clinically superior to that drug as determined by the plan.
 That are ordered by a dentist or prescribed by an oral surgeon in relation to the removal of
teeth, or prescription drugs for the treatment of a dental condition.
 That are considered oral dental preparations and fluoride rinses, except pediatric fluoride
tablets or drops as specified on the preferred drug guide (formulary).
 That are non-preferred drugs, unless non-preferred drugs are specifically covered as
described in your schedule of benefits. However, a non-preferred drug will be covered if in
the judgment of the prescriber there is no equivalent prescription drug on the preferred
drug guide (formulary) or the product on the preferred drug guide (formulary) is ineffective
in treating your disease or condition or has caused or is likely to cause an adverse reaction
or harm you. That are not considered covered or related to a non-covered service.
 That are being used or abused in a manner that is determined to be furthering an addiction
to a habit-forming substance, the use of or intended use of which would be illegal,
unethical, imprudent, abusive, not medically necessary, or otherwise improper; and drugs
obtained for use by anyone other than the member identified on the ID card.
 We reserve the right to include only one manufacturer’s product on the preferred drug
guide (formulary) when the same or similar drug (that is, a drug with the same active
ingredient), supply or equipment is made by two or more different manufacturers.
 We reserve the right to include only one dosage or form of a drug on the preferred drug
guide (formulary) when the same drug (that is, a drug with the same active ingredient) is
available in different dosages or forms from the same or different manufacturers. The
product in the dosage or form that is listed on our preferred drug guide (formulary) will be
covered at the applicable copayment or coinsurance.
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Progesterone

Progesterone for the treatment of premenstrual syndrome (PMS) and compounded natural
hormone therapy replacement.
Prophylactic drugs for travel
Refills

Refills dispensed more than one year from the date the latest prescription order was
written, or as otherwise permitted by applicable law of the jurisdiction in which the drug is
dispensed.
Replacement of lost or stolen prescriptions except in the case of an emergency or
disaster.
Tobacco use

Any treatment, drug, service or supply to stop or reduce smoking or the use of other
tobacco products or to treat or reduce nicotine addiction, dependence or cravings,
including, medications, nicotine patches and gum unless recommended by the United States
Preventive Services Task Force (USPSTF).
Test agents except diabetic test agents
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Who provides the care
Just as the starting point for coverage under your policy is whether the services and supplies are eligible
health services, the foundation for getting covered care is the network. This section tells you about
network.
Network providers
We have contracted with providers in the service area to provide eligible health services to you. These
providers make up the network for your policy. For you to receive the network level of benefits, you
must use network providers for eligible health services. There are three exceptions:
 Emergency services – refer to the description of emergency services and urgent care in the
Eligible health services under your policy section.
 Urgent care – refer to the description of emergency services and urgent care in the Eligible
health services under your policy section.
 Network provider not reasonably available – You can get eligible health services under your
policy that are provided by an out-of-network provider if an appropriate network provider is
not reasonably available. You must request access to the out-of-network provider in advance
and we must agree. Contact Member Services at the toll-free number on your ID card for
assistance.
You may select a network provider from the directory or by logging on to our website at
www.aetna.com. You can search our online directory, www.aetna.com/individuals-families/cb/northcarolina/provider-search/caromont-health-hpn.html, for names and locations of providers.
You will not have to submit claims for treatment received from network providers. Your network
provider will take care of that for you. And we will directly pay the network provider for what the policy
owes.
Your PCP
For you to receive the network level of benefits eligible health services must be accessed through your
PCP’s office. We encourage you to access eligible health services through a PCP. They will provide you
with primary care.
A PCP can be any of the following providers available under your policy:
 General practitioner
 Family physician
 Internist
 Pediatrician
 OB, GYN, and OB/GYN
How do you choose your PCP?
You can choose a PCP from the list of PCPs in our directory.
Each covered family member is encouraged to select their own PCP. You may each select your own PCP.
You should select a PCP for your covered dependent if they are a minor or cannot choose a PCP on their
own.
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You may pick a specialist as your PCP if you have an issue that is:
 serious
 requires specialized care
 chronic
 degenerative
 disabling
 a life-threatening disease or condition that requires specialized care
You may select as your PCP a participating specialist with expertise in the disease or condition.
However, if we determine that the specialist would not appropriately coordinate care, we may
deny that specialist as a PCP. Selection of a specialist as your PCP shall be made under a
treatment plan we approve, in consultation with the specialist and you or your designee, after
your PCP, if any, is notified.
How do you choose your PCP?
You can choose a PCP from the list of PCPs in our directory.
Each covered family member is encouraged to select their own PCP. You may each select your own PCP.
You should select a PCP for your covered dependent if they are a minor or cannot choose a PCP on their
own.
What will your PCP do for you?
Your PCP will coordinate your medical care or may provide treatment. They may send you to other
network providers.
Your PCP can also:
 Order lab tests and radiological services.
 Prescribe medicine or therapy.
 Arrange a hospital stay or a stay in another facility.
Your PCP will give you a written or electronic referral to see other network providers.
How do I change my PCP?
You may change your PCP at any time. You can call us at the toll-free number on your ID card or log on
to your my.aetna.com secure member website at www. aetna.com to make a change.
What happens if I do not select a PCP?
Because having a PCP is so important, we may choose one for you. We will notify you of the PCP’s name,
address and telephone number.
Your eligible health services will be limited to care provided by network providers, emergency services
and urgent care services.
Keeping a provider you go to now (continuity of care)
You may have to find a new provider when:
 You join the policy and the provider you have now is not in the network.
 You are already a member of Aetna and your provider stops being in our network.
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However, in some cases, you may be able to keep going to your current provider to complete a
treatment or to have treatment that was already scheduled. This is called continuity of care.
Request for approval
Length of transitional
period
How claim is paid
If you are a new enrollee and your
provider is a tier 1 network provider
If you are a new enrollee and
your tier 2 network provider
stops participation with us
You need to complete a Transition of
Coverage Request form and send it to us.
You can get this form by contacting
Member Services at the number on the
back of your ID card.
Care will continue during a transitional
period for up to 90 days from your
effective date of coverage under this
policy.
You or your provider should call us
for approval to continue any care.
Your claim will be paid at the tier 1
network provider cost sharing level.
Care will continue during a
transitional period for up to90
days. This date is based on the
date the provider terminated their
participation with us.
Your claim will be paid at the nontier 1 network provider cost
sharing level.
If you are a new enrollee and your provider is not contracted with
Aetna
Request for approval
Length of transitional
period
How claim is paid
You need to complete a Transition of Coverage Request form and send it to us.
You can get this form by contacting Member Services at the number on the
back of your ID card.
Care will continue during a transitional period for up to 90 days from your
effective date of coverage under this policy.
Your claim will be paid at the tier 2 network provider cost sharing level.
If you are pregnant and have entered your second trimester, the transitional period will include the time
required for postpartum care directly related to the delivery.
We will authorize coverage for the transitional period only if the provider agrees to our usual terms and
conditions for contracting providers.
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What the policy pays and what you pay
Who pays for your eligible health services – Aetna under this policy, both of us, or just you? That
depends. This section gives the general rule and explains these key terms:
 Your deductible
 Your copayments/coinsurance
 Your maximum out-of-pocket limit
We also remind you that sometimes you will be responsible for paying the entire bill – for example, if
you get care that is not an eligible health service.
The general rule
When you get eligible health services:
 You pay for the entire expense up to any deductible limit; and then
 The policy and you share the expense up to any maximum out-of-pocket limit. The schedule of
benefits lists how much your policy pays and how much you pay for each type of health care
service. Your share is called a copayment/coinsurance; and then
 The policy pays the entire expense after you reach your maximum out-of-pocket limit.
When we say “expense” in this general rule, we mean negotiated charge for a network provider, and
recognized charge for an out-of-network provider. See the Glossary section for what these terms mean.
Important exception – when your policy pays all
Your policy pays the entire expense for all eligible health services under the preventive care and
wellness benefit.
Important exceptions – when you pay all
You pay the entire expense for an eligible health service:
 When you get a health care service or supply that is not medically necessary. See the Medical
necessity and precertification requirements section.

When your policy requires precertification, your physician requested it, we refused it, and you
get an eligible health service without precertification. See the Medical necessity and
precertification requirements section.

Usually, when you get an eligible health service from someone who is not a network provider.
See the Who provides the care section.
In all these cases, the provider may require you to pay the entire charge. And any amount you pay will
not count towards your deductible or towards your maximum out-of-pocket limit.
Special financial responsibility
You are responsible for the entire expense of:
 Cancelled or missed appointments
Neither you nor we are responsible for:
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

Charges for which you have no legal obligation to pay
Charges that would not be made if you did not have coverage
Where your schedule of benefits fits in
How your deductible works
Your deductible is the amount you need to pay for eligible health services before your policy begins to
pay for eligible health services.
Individual deductible is the amount you pay per individual for eligible health services before your policy
begins to pay for eligible health services.
Family deductible applies when two or more family members are enrolled in your plan. The family
deductible is met by any combination of family members. It is a per person cost limitation when
dependents are enrolled.
Your schedule of benefits shows the deductible amounts for your policy.
How your copayment/coinsurance works
Your copayment/coinsurance is the amount you pay for eligible health services after you have paid
your deductible. Your schedule of benefits shows you which copayments/coinsurance you need to pay
for specific eligible health services.
You will pay the physician, PCP copayment/coinsurance when you receive eligible health services from
any PCP.
You will pay the PCP copayment/coinsurance when you select a PCP and get eligible health services
from them.
You will pay less cost sharing when you use a tier 1 network provider for eligible health services from
them. Your cost sharing will be generally higher when tier 2 network providers are used.
How your cost sharing works
The way the cost sharing works under this policy, you pay your copayment then you pay any remaining
deductible and then you pay your coinsurance. Your copayment does not apply towards any
deductible. The cost sharing under this policy works differently than policies where you are required to
pay the deductible before eligible health services are covered benefits under the policy, and then you
pay your copayment and coinsurance.
How your maximum out-of-pocket limit works
You will pay your deductible and copayments/coinsurance up to the maximum out-of-pocket limit for
your policy. Your schedule of benefits shows the maximum out-of-pocket limits that apply to your
policy. Once you reach your maximum out-of-pocket limit, your policy will pay for covered benefits for
the remainder of that calendar year.
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Important note:
See the schedule of benefits for any deductibles, copayments/coinsurance, maximum out-of-pocket
limit and maximum age, visits, days, hours, admissions that may apply.
Here is an example of costs for an In-Network Participating Provider.
IN-NETWORK RULES
What the Participating Provider bills.
Allowed Amount based on the In-Network Provider’s
Contract with Us.
In-Network Deductible.
(C)
Subtract Deductible from (B).
Difference between (A) and (B).
(A)
(B)
PLEASE NOTE: You don’t pay the difference because We have a
Contract with the Provider.
Total We Pay.
Total You Pay.
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IN-NETWORK AMOUNTS
$12,000
$10,000
$3,000
$10,000 - $3,000 = $7,000
$12,000 - $10,000 = $2,000
(You are not required to pay this
amount)
$10,000 (Allowed Amount)
– $3,000 (Deductible)
$7,000
$3,000 (Deductible)
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When you disagree - claim decisions and appeals procedures
In the previous section, we explained how you and we share responsibility for paying for your eligible
health services.
When a claim comes in, we decide and tell you how you and we will split the expense. We also explain
what you can do if you think we got it wrong.
Types of claims and communicating our claim decisions
Your network provider will send us a claim on your behalf. And we will review that claim for payment to
the provider.
There are different types of claims. The amount of time that we have to tell you about our decision on a
claim depends on the type of claim. The section below will tell you about the different types of claims.
Urgent care claim
An urgent claim is one for which delay in getting medical care could put your life or health at risk. Or a
delay might put your ability to regain maximum function at risk. Or it could be a situation in which you
need care to avoid severe pain.
If you are pregnant, an urgent claim also includes a situation that can cause serious risk to the health of
your unborn baby.
Pre-service claim
A pre-service claim is a claim that involves services you have not yet received and which we will pay for
only if we precertify them.
Post-service claim
A post service claim is a claim that involves health care services you have already received.
Concurrent care claim extension
A concurrent care claim extension occurs when you ask us to approve more services than we already
have approved. Examples are extending a hospital stay or adding a number of visits to a provider. We
will remain responsible for approved services until our decision for the extension is reached.
Concurrent care claim reduction or termination
A concurrent care claim reduction or termination occurs when we decide to reduce or stop payment for
an already approved course of treatment. We will notify you of such a determination. You will have
enough time to file an appeal. Your coverage for the service or supply will continue until you receive a
final appeal decision from us or an external review organization if the situation is eligible for external
review.
During this continuation period, you are still responsible for your share of the costs, such as
copayments/coinsurance and deductibles that apply to the service or supply. If we uphold our decision
at the final internal appeal, you will be responsible for all of the expenses for the service or supply
received during the continuation period.
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The chart below shows a timetable view of the different types of claims and how much time we have to
tell you about our decision.
We may need to tell your physician about our decision on some types of claims, such as a concurrent
care claim, or a claim when you are already receiving the health care services or are in the hospital.
Type of notice
Initial determination (us)
Urgent care
claim
72 hours
Pre-service
claim
15 days
Post-service
claim
30 days
Concurrent
care claim
24 hours for
urgent request*
15 calendar
days for nonurgent request
Not applicable
Not applicable
Extensions
None
15 days
15 days
Additional information
72 hours
15 days
30 days
request (us)
Response to additional
48 hours
45 days
45 days
Not applicable
information request (you)
*We have to receive the request at least 24 hours before the previously approved health care services
end.
Adverse benefit determinations
An adverse benefit determination means:
 A denial,
 reduction,
 termination of,
 failure to provide, or
 make payment (in whole or in part) for
a benefit, resulting from the utilization review, as well as a failure to cover an item or service for
which benefits are otherwise provided because it is determined to be experimental or
investigational, not medically necessary or appropriate.
We pay many claims at the full rate negotiated with a network provider, except for your share of the
costs. But sometimes we pay only some of the claim. And sometimes we deny payment entirely. Any
time we deny even part of the claim that is an “adverse benefit determination” or “adverse decision”. It
is also an “adverse benefit determination” if we rescind your coverage entirely.
If we make an adverse benefit determination, we will tell you in writing.
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The difference between a complaint and an appeal
A Complaint
You may not be happy about a network provider or an operational issue, and you may want to
complain. You can call or write Member Services the Exchange. Your complaint should include a
description of the issue. You should include copies of any records or documents that you think are
important. We will review the information and provide you with a written response within 30 calendar
days of receiving the complaint. We will let you know if we need more information to make a decision.
A Grievance
A grievance is a written or oral complaint submitted to Aetna by you or your designee about any of the
following:
 a decision, policy or action related to availability, delivery, or quality of health care services. A
written complaint submitted by you about a decision rendered solely on the basis that the
health benefit plan contains a benefits exclusion for the health care service in question is not an
adverse benefit determination if the exclusion of the specific service requested is clearly stated
in the certificate of coverage.
 Claims payment or handling; or reimbursement for services.
 The contractual relationship between you and the health plan.
 The outcome of an appeal of a noncertification under North Carolina general statute.
An Appeal
You can ask us to re-review an adverse benefit determination. This is called an appeal. You can appeal to
us verbally or in writing.
Appeals of adverse benefit determinations
You can appeal our adverse benefit determination. The adverse benefit determination also includes
grievance. We will assign your appeal to someone who was not involved in making the original decision.
You must file an appeal within 180 calendar days from the time you receive the notice of an adverse
benefit determination.
You can appeal by sending a written appeal to the address on the notice of adverse benefit
determination. Or you can call Member Services at the number on your ID card. You need to include:
 Your name
 A copy of the adverse benefit determination
 Your reasons for making the appeal
 Any other information you would like us to consider
Another person may submit an appeal for you, including a provider. That person is called an authorized
representative. You need to tell us if you choose to have someone else appeal for you (even if it is your
provider). You should fill out an authorized representative form telling us that you are allowing
someone to appeal for you. You can get this form by contacting us.
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Noncertification
A noncertification is a determination by Aetna that an admission, availability of care, continued stay, or
other health care service has been reviewed and, based upon the information provided, does not meet
Aetna’s requirements for medical necessity, appropriateness, health care setting, level of care or
effectiveness, or does not meet the prudent layperson standard for coverage of emergency services in
NCGS 58-3-190, and the requested service is therefore denied, reduced, or terminated.
A "noncertification" is not a decision rendered solely on the basis that the health benefit plan does not
provide benefits for the health care service in question, if the exclusion of the specific service requested
is clearly stated in the certificate of coverage.
A "noncertification" includes any situation in which Aetna makes a decision about a covered person's
condition to determine whether a requested treatment is experimental, investigational, or cosmetic,
and the extent of coverage under the health benefit plan is affected by that decision.
Notice of non-certification
A written notification of a noncertification shall include all reasons for the noncertification.
Urgent care or pre-service claim appeals
If your claim is an urgent claim or a pre-service claim, your provider may appeal for you without having
to fill out a form.
We will provide you with any new or additional information that we used or that was developed by us to
review your claim. We will provide this information at no cost to you before we give you a decision at
your last available level of appeal. This decision is called the final adverse benefit determination. You can
respond to this information before we tell you what our final decision is.
Timeframes for deciding appeals
The amount of time that we have to tell you about our decision on an appeal claim depends on the type
of claim. The chart below shows a timetable view of the different types of claims and how much time we
have to tell you about our decision.
Aetna’s timeframe for responding to an appeal for adverse benefit determination
Type of notice
Urgent care
claim
Pre-service
claim
Post-service
claim
Concurrent
care claim
Appeal determinations at
each level (us)
Extensions
72 hours
30 days
60 days
As appropriate
to type of claim
None
None
None
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Aetna’s timeframe for responding to an appeal for utilization review claims
Type of claim
Response time from receipt of appeal
Urgent care claim
Within 72 hours
Review provided by our personnel not involved in making the adverse
benefit determination.
Pre-service claim
Within 15 calendar days
Concurrent care claim
extension
Post-service claim
Review provided by our personnel not involved in making the adverse
benefit determination.
Treated like an urgent care claim or a pre-service claim depending on the
circumstances
Within 30 calendar days
Review provided by our personnel not involved in making the adverse
benefit determination.
Exhaustion of appeals process
In most situations you must complete the one level of appeal with us before you can take these other
actions:
 Contact Health Insurance Smart NC at the North Carolina Department of Insurance to request an
investigation of a complaint or appeal. (See contact information below)
 File a complaint or appeal with Health Insurance Smart NC at the North Carolina Department of
Insurance. (See contact information below)
 Appeal through an external review process.
 Pursue arbitration, litigation or other type of administrative proceeding.
But sometimes you do not have to complete the one level of appeals process before you may take other
actions. These situations are:
 You have an urgent claim or a claim that involves ongoing treatment. You can have your claim
reviewed internally and at the same time through the external review process.
 We did not follow all of the claim determination and appeal requirements of the State or of the
Federal Department of Health and Human Services. But, you will not be able to proceed directly
to external review if:
- The rule violation was minor and not likely to influence a decision or harm you.
- The violation was for a good cause or beyond our control.
- The violation was part of an ongoing, good faith exchange between you and us.
External review
External review is a review done by people in an organization outside of Aetna. This is called an external
review organization (ERO).
You have a right to external review only if:
 Our claim decision involved medical judgment.
 We decided the service or supply is not medically necessary or not appropriate.
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

We decided the service or supply is experimental or investigational.
You have received an adverse determination.
If our claim decision is one for which you can seek external review, we will say that in the notice of
adverse benefit determination or final adverse benefit determination we send you. That notice also will
describe the external review process. It will include a copy of the Request for External Review form at
the final adverse determination level.
You must submit the Request for External Review Form:
 To Aetna
 Within 180 calendar days of the date you received the decision from us
 And you must include a copy of the notice from us and all other important information that
supports your request
You will pay for any information that you send and want reviewed by the ERO. We will pay for
information we send to the ERO plus the cost of the review.
Aetna will:
 Contact the ERO that will conduct the review of your claim.
 Assign the appeal to one or more independent clinical reviewers that have the proper expertise
to do the review.
 Consider appropriate credible information that you sent.
 Follow our contractual documents and your schedule of benefits.
 Send notification of the decision within 45 calendar days of the date we receive your request
form and all the necessary information.
We will stand by the decision that the ERO makes, unless we can show conflict of interest, bias or fraud.
How long will it take to get an ERO decision?
We will tell you of the ERO decision not more than 45 calendar days after we receive your Notice of
External Review Form with all the information you need to send in.
But sometimes you can get a faster external review decision. Your provider must call us or send us a
Request for External Review Form.
There are two scenarios when you may be able to get a faster external review:
For initial adverse determinations
Your provider tells us that a delay in your receiving health care services would:
 Jeopardize your life, health or ability to regain maximum function, or
 Be much less effective if not started right away (in the case of experimental or investigational
treatment)
For final adverse determinations
Your provider tells us that a delay in your receiving health care services would:
 Jeopardize your life, health or ability to regain maximum function
 Be much less effective if not started right away (in the case of experimental or investigational
treatment), or
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
The final adverse determination concerns an admission, availability of care, continued stay or
health care service for which you received emergency services, but have not been discharged
from a facility
If your situation qualifies for this faster review, you will receive a decision within 72 hours of us
getting your request.
Please note the availability of assistance from the Managed Care Patient Assistance Program
(MCPAP) is offered through Health Insurance Smart NC. Contact Information:
North Carolina Department of Insurance
Health Insurance Smart NC
1201 Mail Service Center
Raleigh, NC 27699-1201
(toll free) 855-408-1212
Fax: 919-807-6865
Email: www.ncdoi.com/smart
Recordkeeping
We will keep the records of all complaints and appeals for at least 10 years.
Fees and expenses
We do not pay any fees or expenses incurred by you in pursuing a complaint or appeal.
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When coverage ends
Coverage can end for a number of reasons. This section tells you how and why coverage ends. And when
you may still be able to continue coverage.
When will your coverage end?
Your coverage under this policy will end if:
 This policy is discontinued.
 You voluntarily stop your coverage by notifying us in writing 31 days in advance of the requested
termination.
 You are no longer eligible for coverage including moving out of the service area.
 You do not make your required premium payment by the end of the grace period.
 There is a discontinuance, under federal or state law, of this product in the state if approved by
the Insurance Department of the jurisdiction where this policy was issued;
 Aetna’s withdrawal, under federal or state law, from the individual market in the state where
this policy was issued if approved by the Insurance Department of the jurisdiction where this
policy was issued.
 We end your coverage.
When will coverage end for any covered dependent?
Coverage for your dependent will end if:
 Your dependent no longer meets the eligibility requirements of the Exchange
 You do not make the required premium contribution toward the cost of dependents’ coverage.
 Your coverage ends for any of the reasons listed above.
In addition, coverage for your domestic partner will end on the earlier of:
 The date this policy no longer allows coverage for domestic partners.
 The date the domestic partnership ends. For a domestic partnership, you should provide a
completed and signed Declaration of Termination of Domestic Partnership to us.
Why would we end your and your covered dependents’ coverage?
We may immediately end your coverage if:
 You commit fraud or misrepresent yourself when you applied for or obtained coverage. You can
refer to the A bit of this and that - Honest mistakes and intentional deception section for more
information on rescissions.
Any statement made is considered a representation and not a warranty. We will only use a
statement during a dispute if it is shared with you and your beneficiary, or the person making
the claim.

You act in such a disruptive way as to prevent or adversely affect our operations or those of a
network provider.
On the date your coverage ends, we will refund to you any prepayments for periods after the date your
coverage ended.
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When can I expect my coverage to end?
We will send you notice if your coverage is ending. This notice will tell you the date that your coverage
ends. Here is how the date is determined (other than the circumstances described above in “Why we
would end your coverage”).
Coverage will end for you and any covered dependents’ immediately following the date on which you
no longer meet the eligibility requirements.
Certificate of Creditable Coverage
You are entitled to a certificate when coverage ends. The certificate states the following:
 Coverage details
 The date of waiting periods
 The date coverage began and ended.
A certificate will be issued:
 When you or your dependent stops being covered for any reason
 When you or your dependent asks within 24 months of coverage ending.
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Special coverage options after your policy coverage ends
This section explains options you may have after your coverage ends under this policy. Your individual
situation will determine what options you will have.
To request an extension of coverage, just call the toll-free Member Services number on your ID card.
How can you extend coverage if you are totally disabled when coverage ends?
Your coverage may be extended if you or your covered dependent are totally disabled when coverage
ends. Only the medical condition which caused the total disability is covered during your extension.
You are “totally disabled” if you cannot work at your own occupation or any other occupation for pay or
profit.
Your dependent is “totally disabled” if that person is incapable of self-sustaining employment by reason
of mental retardation or physical handicap; and chiefly dependent upon you for support and
maintenance.
You may extend coverage only for services and supplies related to the disabling condition until the
earliest of:
 When you or your covered dependent are no longer totally disabled
 When you become covered by another health benefits policy
 12 months of coverage
How can you extend coverage when getting inpatient care when coverage ends?
Your coverage may be extended if you or your dependents are getting inpatient care in a hospital or
skilled nursing facility when coverage ends.
Benefits are extended for the condition that caused the hospital or skilled nursing facility stay or for
complications from the condition. Benefits aren’t extended for other medical conditions.
You can continue to get care for this condition until the earliest of:
 When you are discharged
 When you no longer need inpatient care
 When you become covered by another health benefits policy
 12 months of coverage
What exceptions are there for dental work completed after your coverage ends?
Your dental coverage may end while you or your covered dependent is in the middle of treatment. The
policy does not cover dental services that are given after your coverage terminates. There is an
exception. The policy will cover the following services if they are ordered while you were covered by the
policy, and installed within 30 days after your coverage ends:
 Inlays
 Onlays
 Crowns
 Removable bridges
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



Cast or processed restorations
Dentures
Fixed partial dentures (bridges)
Root canals
Ordered means:
 For a denture: the impressions from which the denture will be made were taken
 For a root canal: the pulp chamber was opened
 For any other item: the teeth which will serve as retainers or supports, or the teeth which are
being restored:
- Must have been fully prepared to receive the item
- Impressions have been taken from which the item will be prepared
How can you extend coverage for hearing services and supplies when coverage ends?
If your coverage ends while you are not totally disabled, your policy will cover hearing services and
supplies within 30 days after your coverage ends if:
 The prescription for the hearing aid is written in the 30 days before your coverage ended.
 The hearing aid is ordered during the 30 days before the date coverage ends.
How can you extend coverage for vision care services and supplies when coverage ends?
If your coverage ends while you are not totally disabled, your policy will cover vision services and
supplies for eyeglasses and contact lenses within 30 days after your coverage ends if:
 A complete vision exam was performed in the 30 days before your coverage ended, and the
exam included refraction.
 The exam resulted in contact or frame lenses being prescribed for the first time, or new contact
or frame lenses ordered due to a change in prescription.
How can you extend coverage for your disabled child beyond the policy age limits?
You have the right to extend coverage for your dependent child beyond the policy age limits. If your
disabled child:
 Is not able to be self-supporting because of mental or physical handicap or disability, and
 Depends mainly on you for support and maintenance.
The right to coverage will continue only as long as a physician certifies that your child still is disabled.
We may ask you to send us proof of the disability within 31days of the date coverage would have ended.
Before we extend coverage, we may ask that your child get a physical exam. We will pay for that exam.
We may ask you to send proof that your child is disabled after coverage is extended. We won’t ask for
this proof more than once a year. You must send it to us within 31 days of our request. If you don’t, we
can terminate coverage for your dependent child.
How can you extend coverage for a child in college on medical leave?
You have the right to extend coverage for your dependent college student who takes a medically
necessary leave of absence from school. The right to coverage will be extended until:
 The earlier of one year after the leave of absence begins, or
 The date coverage would otherwise end.
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To extend coverage the leave of absence must:
 Begin while the dependent child is suffering from a serious illness or injury.
 Cause the dependent child to lose status as a full-time student under the policy, and
 Be certified by the treating doctor as medically necessary due to a serious illness or injury.
The doctor treating your child will be asked to keep us informed of any changes.
How can I extend coverage for a dependent after I die?
Your dependents can continue coverage after your death if:
 You were covered at the time of your death
 The request is made within 31 days after your death, and
 Payment is made for the coverage.
Your dependent’s coverage will end on the earliest date:
 The end of the 12th month period after your death
 They no longer meet the definition of dependent
 Dependent coverage stops under the plan
 The dependent becomes covered by another health benefits plan
 Any required contributions stop, or
 The date your spouse remarries
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A bit of this and that
We gathered a number of provisions here. They talk about several different things, so we call this part “a
bit of this and that.”
Administrative provisions
How you, we and the Exchange will interpret this policy
We prepared this policy according the applicable federal laws and state laws. You and we will interpret it
according to these laws. Also, you are bound by our interpretation of this policy when we administer
your coverage, so long as we use reasonable discretion.
How we administer this policy
We apply policies and procedures we’ve developed to administer this policy.
Who’s responsible to you
We are responsible to you for what our employees and other agents do.
We are not responsible for what is done by your providers. Even network providers are not our
employees or agents.
Coverage and services
Your coverage can change
Your coverage is defined by this policy. This document may have amendments or riders too. Under
certain circumstances, we or the law may require a change in your policy. Only Aetna may waive a
requirement of your policy. No other person – including your provider – can do this.
If a service cannot be provided to you
Sometimes things happen that are outside of our control. These are things such as natural disasters,
epidemics, fire and riots.
We will try hard to get you access to the services you need even if these things happen. But if we can’t,
we may refund you any unearned premium.
Financial Sanctions Exclusions
If coverage provided under this policy violates or will violate any economic or trade sanctions, the
coverage is immediately considered invalid. For example, Aetna companies cannot make payments for
health care or other claims or services if it violates a financial sanction regulation. This includes
sanctions related to a blocked person or a country under sanction by the United States, unless it is
permitted under a written license from the Office of Foreign Asset Control (OFAC). For more
information visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.
Workers’ Compensation
Treatment of occupational injuries and diseases which are paid or payable under the North Carolina
Workers’ Compensation Act but only to the extent that eligible health services are the liability of the
Member, the contract holder, or workers’ compensation insurance carrier according to the final
adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina
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Industrial Commission approving a settlement agreement under the North Carolina Workers’
Compensation Act.
Legal action
You cannot take any legal action against Aetna for any expense or bill until you complete the appeal
process. And you cannot take any action until 60 days after we receive written submission of claim.
No such action shall be brought after the expiration of 3 years after the time written proof of loss is
required to be furnished.
Benefits Not Transferable
You and/or your covered dependents are the only persons entitled to receive benefits under this policy.
Conformity with Law
Any provision of this policy which, on its effective date, is in conflict with any applicable statute,
regulation or other law is hereby amended to conform with the minimum requirements of such law.
Successor policyholder
If the policyholder ceases to be the insured other than by termination of the policy, the policyholder's
covered spouse, or domestic partner, if any, will become the policyholder. In the case of an insured
dependent child, the parent or legal guardian in whose name the coverage under the policy is issued is
considered the policyholder. If at the end of a premium period there is no policyholder, this policy will
terminate.
Child only coverage
In the case of child only coverage, the parent or legal guardian in whose name the coverage under the
policy is issued is considered the policyholder. As a parent or legal guardian, the policyholder has
subscribed on behalf of the child for the benefits described in this policy. It is the policyholder's
responsibility to assure a child’s compliance with any and all terms and conditions outlined in this policy.
Effect of benefits under other policies
Non-Duplication of Benefits
If, while covered under this policy, you are also covered by another Aetna individual coverage policy:
 You will be entitled only to the benefits of the policy with the greater benefits, and
 we will refund any premium charges received under the policy with the lesser benefits covering
the time period both policies were in effect.
If while covered under this policy, you are also covered under an Aetna group plan:

You will be entitled only to the benefits of the group policy.
We will refund any premium received under the individual policy covering the period both were in
effect.
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This provision does not apply to Medicaid policies and payment under other governmental plans, unless
permitted by law.
Physical examinations and evaluations
At our expense, we have the right to have a physician of our choice examine you. This will be done at all
reasonable times while certification or a claim for benefits is pending or under review.
Records of expenses
You should keep complete records of your expenses. They may be needed for a claim.
Things that would be important to keep are:
• Names of physicians, dentists and others who furnish services
• Dates expenses are incurred
• Copies of all bills and receipts
Honest mistakes and intentional deception
Honest mistakes
You may make an honest mistake in your application for coverage. When we learn of the mistake, we
may make a fair change in premium contribution or in your coverage. If we do, we will tell you what the
mistake was. We won’t make a change if the mistake happened more than 1-2 years before we learned
of it.
Intentional deception
If we learn that you defrauded us or you intentionally misrepresented material facts, we can take
actions that can have serious consequences for your coverage. These serious consequences include, but
are not limited to:
 Loss of coverage, starting at some time in the past. This is called rescission.
 Loss of coverage going forward.
 Denial of benefits.
 Recovery of amounts we already paid.
We also may report fraud to criminal authorities.
Rescission means you lose coverage both going forward and going backward. If we paid claims for your
past coverage, we will want the money back.
You have special rights if we rescind your coverage.
 We will give you 30 days advanced written notice of any rescission of coverage.
 You have the right to an Aetna appeal.
 You have the right to a third party review conducted by an independent external review
organization.
Some other money issues
Assignment of benefits
When you see a network provider they will usually bill us directly. When you see an out-of-network
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provider we may choose to pay you or to pay the provider directly. To the extent allowed by law, we
will not accept an assignment to an out-of-network provider.
Recovery of overpayments
We sometimes pay too much for eligible health services or pay for something that this policy doesn’t
cover. If we do, we can require the person we paid – you or your provider – to return what we paid. If
we don’t do that we have the right to reduce any future benefit payments by the amount we paid by
mistake.
When you are injured
If someone else caused you to need care – say, a careless driver who injured you in a car crash – you
may have a right to get money. We are entitled to that money, up to the amount we pay for your care.
We have that right no matter who the money comes from – for example, the other driver, your
employer or another insurance company.
To help us get paid back, you are doing two things now:
 You are agreeing to repay us from money you receive because of your injury.
 You are giving us a right to seek money in your name, from any person who causes you injury
and from your own insurance. We can seek money only up to the amount we paid for your care.
You are agreeing to cooperate with us so we can get paid back. For example, you’ll tell us if you
seek money for your injury or illness. You’ll hold any money you receive until we are paid. And
you’ll give us the right to money you get, ahead of everyone else.
We don’t have to reduce the amount we’re due for any reason, even to help pay your lawyer or pay
other costs you incurred to get a recovery.
Your health information
We will protect your health information. We use and share it to help us process your providers’ claims
and manage your Policy. You can get a free copy of our Notice of Privacy Practices. Just call Member
Services at the toll-free number on your ID card. When you accept coverage under this policy, you agree
to let your providers share your information with us. We will need information about your physical and
mental condition and care.
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Glossary
Aetna or Aetna’s
Aetna Health Inc., is a Pennsylvania corporation licensed by the state of North Carolina to operate as a
health maintenance organization.
Ambulance
A vehicle staffed by medical personnel and equipped to transport an ill or injured person.
Behavioral health provider
An individual professional that is properly licensed or certified to provide diagnostic and/or therapeutic
services for mental disorders and substance abuse under the laws of the jurisdiction where the
individual practices.
Biosimilar prescription drug(s)
A biological prescription drug that is highly similar to a U.S. Food and Drug Administration (FDA) –
licensed reference biological prescription drug notwithstanding minor differences in clinically inactive
components, and for which there are no clinically meaningful differences between the highly similar
biological prescription drug and the reference biological prescription drug in terms of the safety, purity,
and potency of the drug. As defined in accordance with U.S. Food and Drug Administration (FDA)
regulations.
Body mass index
This is a degree of obesity and is calculated by dividing your weight in kilograms by your height in meters
squared.
Bone mass measurement
A scientifically proven radiologic, radioisotopic, or other procedure performed to identify bone mass or
detect bone loss.
Brand-name prescription drug(s)
A U.S. Food and Drug Administration (FDA) approved prescription drug with a branded name assigned
to it by the manufacturer or distributor, and indicated by Medi-span or similar publication designated by
Aetna.
Calendar year
A period of 12 months that begins on January 1st and ends on December 31st.
Coinsurance
The specific percentage you have to pay for a health care service listed in the schedule of benefits.
Contract year
A period of 1 year beginning on the contract holder’s effective date of coverage.
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Copay, copayments
The specific dollar amount you have to pay for a health care service listed in the schedule of benefits.
Copayments may be changed by Aetna upon 30 days written notice to the policyholder.
Cosmetic
Services, drugs or supplies that are primarily intended to alter, improve or enhance your appearance.
Cosmetic Surgery
Any non-medically necessary surgery or procedure whose primary purpose is to improve or change the
appearance of any portion of the body to improve self-esteem, but which does not restore bodily
function, correct a diseased state, physical appearance, or disfigurement caused by an accident, birth
defect, or correct or naturally improve a physiological function. cosmetic surgery includes, but is not
limited to, ear piercing, rhinoplasty, lipectomy, surgery for sagging or extra skin, any augmentation or
reduction procedures (e.g., mammoplasty, liposuction, keloids, rhinoplasty and associated surgery) or
treatment relating to the consequences or as a result of cosmetic surgery.
Covered benefit(s)
Eligible health services that meet the requirements for coverage under the terms of this policy,
including:
 They are medically necessary.
 You received precertification if required.
Custodial care
Services and supplies mainly intended to help meet your activities of daily living or other personal
needs. Care may be custodial care even if it is prescribed by a physician or given by trained medical
personnel.
Deductible(s)
The amount you pay for eligible health services per calendar year before your policy starts to pay as
listed in the schedule of benefits.
Dental provider(s)
Any individual legally qualified to provide dental services or supplies. This may be any of the following:
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Any dentist;
Group;
Organization;
Dental facility; or
Other institution or person.
Dentist(s)
A legally qualified Dentist or a Physician licensed to do the dental work he or she performs.
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Dependent(s)
A dependent is the one of the following members of the policyholder's family, who are residents of the
state in which the policy was issued and have been approved by Aetna, they include:
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Your spouse .
Your domestic partner. A domestic partner under this policy is a person who certifies the
following:
 He or she is recognized as a domestic partner in accordance with applicable state law.; and
 He or she is not in the relationship solely for the purpose of obtaining health insurance
coverage; and
 He or she is not married or legally separated from anyone else; and
 He or she has not registered as a member of another domestic partnership within the past
six months; and
 He or she can demonstrate interdependence with you through at least three of the
following:
o Common ownership or lease of real property (joint deed, mortgage or lease
agreement);
o
Driver’s license listing a common address;
o
Utility bills listing both names;
o
Proof of joint bank accounts or credit accounts;
o
Proof of designation as the primary beneficiary for life insurance or retirement benefits,
or primary beneficiary designation under your will; or
o
Assignment of a durable property power of attorney or health care power of attorney.
Your or your covered spouse’s, or your covered domestic partner’s child(ren) who are under 26
years of age.
Child(ren) include:
 Your biological child(ren);
 Your stepchild(ren);
 Your legally adopted child(ren) or child(ren) in process of adoption;
 Your foster child(ren);
 Any child(ren) for whom you are responsible under court order.
Tier 1 network provider
A network provider listed in the directory under the Best results for your policy tab as a Savings Plus
provider for your policy. This plan is designed to lower your out-of-pocket costs when you use a tier 1
network provider for eligible health services. Your cost sharing will be lower when you use a tier 1 network
provider.
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Detoxification
The process where an alcohol or drug intoxicated, or alcohol or drug dependent, person is assisted
through the period of time needed to eliminate the:
 Intoxicating alcohol or drug
 Alcohol or drug-dependent factors
 Alcohol in combination with drugs
This could be done by metabolic or other means determined by a physician. The process must keep the
physiological risk to the patient at a minimum. And if it takes place in a facility, the facility must meet any
applicable licensing standards established by the jurisdiction in which it is located.
Directory
The list of network providers for your policy. The most up-to-date directory for your policy appears at
www.aetna.com under the www.aetna.com/individuals-families/cb/north-carolina/providersearch/caromont-health-hpn.html label. When searching www.aetna.com/individualsfamilies/cb/north-carolina/provider-search/caromont-health-hpn.html, you need to make sure that you
are searching for providers that participate in your specific policy. Network providers may only be
considered for certain Aetna policies. When searching for network dental providers, you need to make
sure you are searching under Pediatric Dental providers.
Durable medical equipment (DME)
Equipment and the accessories needed to operate it, that is:
 Made to withstand prolonged use
 Mainly used in the treatment of an illness or injury
 Suited for use in the home
 Not normally used by people who do not have an illness or injury
 Not for altering air quality or temperature
 Not for exercise or training
Effective date of coverage
The date your and your dependents’ coverage begins under this policy as noted in Aetna’s records.
Eligible health services
The health care services and supplies listed in the Eligible health services under your policy section and
not carved out or limited in the exceptions section or in the schedule of benefits.
Emergency medical condition
A medical condition resulting in acute symptoms of sufficient severity, including, but not limited to,
severe pain, or by acute symptoms developing from a chronic medical condition that would lead a
prudent layperson, possessing an average knowledge of health and medicine, to reasonably expect that
if you don’t get immediate medical attention to result in:
 Placing your health, or with respect to a pregnant woman, the health of the woman or her unborn
child, in serious jeopardy
 Serious loss to bodily function
 Serious loss of function to a body part or organ
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Emergency services
Health care items and services necessary to screen for or treat an emergency medical condition
available in a hospital’s emergency room until the condition is stabilized. This includes prehospital care
and ancillary services available to the emergency department.
Essential Health Benefits.
As required by the federal Affordable Care Act (“ACA”):
 Ambulatory patient service.
 Emergency service.
 Hospitalization.
 Maternity and newborn care.
 Mental health and substance abuse service, including behavioral health treatment.
 Prescription drugs.
 Rehabilitative and habilitative service and devices.
 Lab service.
 Preventive care.
 Chronic disease management.
 Pediatric services, including dental and vision.
Experimental or investigational
A drug, device, procedure, or treatment that we find is experimental or investigational because:
 There is not enough outcome data available from controlled clinical trials published in the peerreviewed literature to validate its safety and effectiveness for the illness or injury involved
 The needed approval by the FDA has not been given for marketing
 A national medical or dental society or regulatory agency has stated in writing that it is
experimental or investigational or suitable mainly for research purposes
 It is the subject of a Phase I, Phase II or the experimental or research arm of a Phase III clinical
trial. These terms have the meanings given by regulations and other official actions and
publications of the FDA and Department of Health and Human Services
 Written protocols or a written consent form used by a facility provider state that it is
experimental or investigational.
 It is provided or performed in a special setting for research purposes.
Generic prescription drug(s)
A prescription drug, whether identified by its chemical, proprietary, or non-proprietary name, that is
accepted by the U.S. Food and Drug Administration (FDA) as therapeutically equivalent and
interchangeable with a drug having an identical amount of the same active ingredient and so indicated
by Medi-span or similar publication designated by Aetna.
Habilitative services
Services that are similar in scope, amount, and duration to benefits covered for rehabilitative services.
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Health professional(s)
A person who is licensed, certified or otherwise authorized by law to provide health care services to the
public. For example, physicians, nurses, and physical therapists.
Hearing aid
Any wearable, non-disposable instrument or device designed to aid or compensate for impaired human
hearing and parts, attachments or accessories.
Home health care agency
An agency licensed, certified or otherwise authorized by applicable state and federal laws to provide
home health care services, such as skilled nursing and other therapeutic services.
Home health care plan
A plan of services prescribed by a physician or other health care practitioner to be provided in the home
setting. These services are usually provided after your discharge from a hospital or if you are
homebound.
Hospice care
Care designed to give supportive care to people in the final phase of a terminal illness and focus on
comfort and quality of life, rather than cure.
Hospice care agency
An agency or organization licensed, certified or otherwise authorized by applicable state and federal
laws to provide hospice care. These services may be available in your home or inpatient setting.
Hospice care program
A program prescribed by a physician or other health professional to provide hospice care
and supportive care to their families.
Hospice facility
An institution specifically licensed, certified or otherwise authorized by applicable state and federal laws
to provide hospice care.
Hospital(s)
A duly licensed State tax-supported institution as a hospital by applicable state and federal laws, and is
accredited as a hospital by The Joint Commission (TJC).
The term “state tax-supported institutions” shall include community mental health centers and other
health clinics which are certified as Medicaid providers.
Illness
Poor health resulting from disease of the body or mind.
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Infertile or infertility
The inability after 12 consecutive months of unsuccessful attempts to conceive a child despite regular
exposure of female reproductive organs to viable sperm.
Injury
Physical damage done to a person or part of their body.
Institutes of Excellence™ (IOE) facility
A facility designated by Aetna in the provider directory as Institutes of Excellence network provider for
specific services or procedures.
Intensive Outpatient Program (IOP)
Clinical treatment provided in a facility or program provided under the direction of a physician. Services
are designed to address a mental disorder or substance abuse issue and may include group, individual,
family or multi-family group psychotherapy, psycho educational services, and adjunctive services such as
medication monitoring.
Jaw joint disorder
This is:
 A Temporomandibular Joint (TMJ) dysfunction or any similar disorder of the jaw joint
 A Myofacial Pain Dysfunction (MPD) of the jaw, or
 Any similar disorder in the relationship between the jaw joint and the related muscles and
nerves.
L.P.N.
A licensed practical nurse or a licensed vocational nurse.
Mail order pharmacy
An establishment where prescription drugs are legally dispensed by mail or other carrier.
Mandated benefits for North Carolina
The following benefits are required by the state of North Carolina:
 Alcoholism/drug abuse treatment – minimum outpatient services
 Clinical trials – clinical trials that meet established criteria
 Congenital defects and anomalies (including cleft lip/palate)
 Dental-related anesthesia and hospital charges for certain individuals
 Diabetes – treatment
 Emergency room care
 Hearing aids
 Inpatient hospital services – minimum inpatient stays following delivery of a baby
 Jaw and Joint disorder (TMJ joint dysfunction)
 Lymphedema – diagnosis and treatment
 Mental health services
 Prescription drugs – access to non-formulary drugs; coverage for certain off label drug use for
the treatment of cancer
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Preventive Care/Screening/Immunization for: bone mass measurement, prescription drug
contraceptives or devices, colorectal cancer screening, newborn hearing screening, ovarian
cancer surveillance tests, mammograms and cervical cancer screening, prostate cancer
screening.
Reconstructive breast surgery following a mastectomy
Maximum out-of-pocket limit(s)
The maximum out-of-pocket amount for payment of copayments and coinsurance including any
deductible, to be paid by you or any covered dependents per calendar year for eligible health services.
Medically necessary/Medical necessity
Medically necessary services or supplies are those covered services or supplies that are:
1) Provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or
disease, and except as allowed under G.S. 58-3-255, not for experimental, investigational, or
cosmetic purposes.
2) Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition,
illness, injury, disease, or its symptoms.
3) Within generally accepted standards of medical care in the community.
4) Not solely for the convenience of the insured, the insured’s family, or the provider.
Nothing precludes an insurer from comparing the cost-effectiveness of alternative services or supplies
when determining which of the services or supplies will be covered.
Mental disorder(s)
An illness commonly understood to be a mental disorder, whether or not it has a physiological or
organic basis, and for which treatment is generally provided by or under the direction of a behavioral
health provider such as a psychiatrist, a psychologist or a psychiatric social worker. Mental disorder
includes substance related disorders.
Morbid obesity/Morbidly obese
This means the body mass index is well above the normal range ( greater than 40 kilograms per meter
squared; or equal to or greater than 35 kilograms per meter squared) and severe medical conditions
may also be present, such as:
• High blood pressure
• A heart or lung condition
• Sleep apnea or
• Diabetes
NAP provider
A National Advantage Program (NAP) is a provider who is not a network provider or National Advantage
Program (NAP) provider and does not appear in the directory for your policy.
Negotiated charge
As to health coverage, (other than prescription drug coverage):
The maximum amount a network provider has agreed to accept for rendering services or providing
supplies to you or your covered dependent under the policy.
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Some providers are part of Aetna’s network for some Aetna policies but are not considered network
providers for your policy. For those providers, the negotiated charge is the amount that provider has
agreed to accept for rendering services or providing prescription drugs to you or your covered
dependent under the policy.
As to prescription drug coverage:
This only applies to in-network coverage and is the amount Aetna has established for each prescription
drug obtained from a network pharmacy under this policy. This negotiated charge may reflect amounts
Aetna has agreed to pay directly to the network pharmacy or to a third party vendor for the
prescription drug, and may include an additional service or risk charge set by Aetna.
The negotiated charge does not reflect any amount Aetna, an affiliate, or a third party vendor, may
receive under a rebate arrangement between Aetna, an affiliate or a third party vendor and a drug
manufacturer for any prescription drug, including prescription drugs on the preferred drug guide
(formulary).
Aetna may receive rebates from the manufacturers of prescription drugs and may receive or pay
additional amounts from or to third parties underprice guarantees. These amounts will not change the
negotiated charge under this policy.
Network pharmacy
A retail, mail order or specialty pharmacy that has contracted with Aetna, an affiliate, or a third party
vendor, to provide outpatient prescription drugs to you.
Network provider(s)
A provider listed in the directory for your policy. However, a NAP provider listed in the NAP directory is
not a network provider.
Tier 2 network provider
A tier 2listed in the directory under the All other results tab as a provider for your policy. When you use
a tier 2 provider your cost sharing will be at a higher level.
Non-Preferred drug(s)
A prescription drug or device that is not listed in the preferred drug guide (formulary).
Out-of-network provider
A provider who is not a network provider or National Advantage Program (NAP) provider and does not
appear in the directory for your policy.
Partial hospitalization treatment
A policy of medical, psychiatric, nursing, counseling, or therapeutic services to treat mental disorders
and substance abuse. The treatment policy must meet these tests:
 It is carried out in a hospital, psychiatric hospital or residential treatment facility on less than a
full-time inpatient basis.
 It is in accordance with accepted medical practice for the condition of the person.
 It does not require full-time confinement.
 It is supervised by a psychiatrist who weekly reviews and evaluates its effect.
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Pharmacy
A network retail, mail order and specialty pharmacy.
Physician(s)
A skilled health care professional trained and licensed to practice medicine under the laws of the state
where they practice; specifically, doctors of medicine or osteopathy.
Precertification, precertify
A requirement that you or your physician contact Aetna before you receive coverage for certain
services.
Preferred drug (formulary)
A prescription drug or device that is listed on the preferred drug guide(formulary).
Preferred drug guide (formulary)
A list of prescription drugs and devices established by Aetna or an affiliate. It includes all covered
prescription drugs and devices. This list can be reviewed and changed by Aetna or an affiliate. A copy of
the preferred drug guide (formulary) is available at your request. Or you can find it on the Aetna
website at www.aetna.com/individuals-families/find-a-medication/leap-plans.html.
Premium
The amount you are required to pay to Aetna to continue coverage.
Prescriber
Any provider acting within the scope of his or her license, who has the legal authority to write an order
for outpatient prescription drugs.
Prescription(s)
As to hearing care:
A written order for the dispensing of prescription electronic hearing aids by otolaryngologist, otologist
or audiologist.
As to prescription drugs:
A written order for the dispensing of a prescription drug by a prescriber. If it is a verbal order, it must
promptly be put in writing by the network pharmacy.
As to vision care:
A written order for the dispensing of prescription lenses or prescription contact lenses by an
ophthalmologist or optometrist.
Prescription drug(s)
A drug, biological, or compounded prescription which, by State and Federal Law, may be dispensed only
by prescription or administered by a person who is acting within his or her capacity as a paid health
professional.
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Primary care physician (PCP)
A physician who:
 The directory lists as a PCP is selected by a person from the list of PCPs in the directory
 Supervises, coordinates and provides initial care and basic medical services to a person as a
family care physician, an internist or a pediatrician
 maintains continuity of patient care
 Is shown on Aetna's records as your PCP
Provider(s)
A physician, other health professional, hospital, skilled nursing facility, home health care agency or
other entity or person licensed or certified under applicable state and federal law to provide health care
services to you. If state law does not specifically provide for licensure or certification, the entity must
meet all Medicare accreditation standards (even if it does not participate in Medicare).
Psychiatric hospital
An institution specifically licensed as a psychiatric hospital by applicable state and federal laws to
provide a program for the diagnosis, evaluation, and treatment of alcoholism, drug abuse, mental
disorders, or mental illnesses.
Psychiatrist
A psychiatrist generally provides evaluation and treatment of mental, emotional, or behavioral
disorders.
Qualified Individual
Someone the Health Insurance Marketplace has determined is eligible to enroll through the Health
Insurance Marketplace in the plan, pursuant to the requirements of 45 C.F.R. 155.305.
R.N.
A registered nurse.
Residential Treatment Facility (Mental Disorders)
This is an institution that meets all of the following requirements:
 Is accredited by one of the following agencies, commissions or committees for the services
being provided: The Joint Commission (TJC), Committee on Accreditation of Rehabilitation
Facilities (!RF), !merican Osteopathic !ssociation’s Healthcare Facilities Accreditation Program
(HFAP) or the Council on Accreditation (COA); or is credentialed by Aetna;
 Meets all applicable licensing standards established by the jurisdiction in which it is located;
 Performs a comprehensive patient assessment preferably before admission, but at least upon
admission;
 Creates individualized active treatment plans directed toward the alleviation of the impairment
that caused the admission;
 Has the ability to involve family/support systems in the therapeutic process;
 Has the level of skilled intervention and provision of care must be consistent with the patient’s
illness and risk;
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Provides access to psychiatric care by a psychiatrist as necessary for the provision of such care;
Provides treatment services that are managed by a behavioral health provider who functions
under the direction/supervision of a medical director; and
 Is not a wilderness treatment program (whether or not the program is part of a licensed
residential treatment facility, or otherwise licensed institution), educational services, schooling
or any such related or similar program, including therapeutic programs within a school setting.
In addition to the above requirements, for Mental Health Residential Treatment Programs:
 A behavioral health provider must be actively on duty 24 hours per day for 7 days a week;
 The patient is treated by a psychiatrist at least once per week; and
 The medical director must be a psychiatrist.
Residential Treatment Facility (Substance Abuse)
This is an institution that meets all of the following requirements:
• Is accredited by one of the following agencies, commissions or committees for the services
being provided: The Joint Commission (TJC), Committee on Accreditation of Rehabilitation
Facilities (CARF), American Osteopathic !ssociation’s Healthcare Facilities !ccreditation Program
(HFAP), or the Council on Accreditation (COA); or is credentialed by Aetna;
• Meets all applicable licensing standards established by the jurisdiction in which it is located;
• Performs a comprehensive patient assessment preferably before admission, but at least upon
admission;
• Creates individualized active treatment plans directed toward the alleviation of the impairment
that caused the admission;
• Has the ability to involve family and/or support systems in the therapeutic process;
• Has the level of skilled intervention and provision of care that is consistent with the patient’s
illness and risk;
• Provides access to psychiatric care by a psychiatrist as necessary for the provision of such care;
• Provides treatment services that are managed by a behavioral health provider who functions
under the direction/supervision of a medical director; and
• Is not a wilderness treatment program (whether or not the program is part of a licensed
residential treatment facility, or otherwise licensed institution), educational services, schooling
or any such related or similar program, including therapeutic programs within a school setting.
In addition to the above requirements, for Chemical Dependence Residential Treatment Programs:
 Is a behavioral health provider or an appropriately state certified professional (for example,
CADC, CAC);
 Is actively on duty during the day and evening therapeutic programming; and
 The medical director must be a physician who is an addiction specialist.
In addition to the above requirements, for Chemical Dependence Detoxification Programs within a
residential setting:
 An R.N. is onsite 24 hours per day for 7 days a week; and
 The care must be provided under the direct supervision of a physician.
Retail pharmacy
A community pharmacy which has contracted with Aetna, an affiliate, or a third party vendor, to
provide covered outpatient prescription drugs to you.
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Room and board
! facility’s charge for your overnight stay and other services and supplies expressed as a daily or weekly
rate.
Semi-private room rate
!n institution’s room and board charge for most beds in rooms with 2 or more beds. If there are no
such rooms, Aetna will calculate the rate based on the rate most commonly charged by similar
institutions in the same geographic area.
Service area
The geographic area in North Carolina as described by the HMO in which an HMO enrolls persons who
either work in the service area, reside in the service area, or work and reside in the service area and as
approved by the Commissioner.
Skilled nursing facility
A facility specifically licensed as a skilled nursing facility by applicable state and federal laws to provide
skilled nursing care.
Skilled nursing facilities also include rehabilitation hospitals and portions of a rehabilitation hospital
and a hospital designated for skilled or rehabilitation services.
Skilled nursing facility does not include institutions that provide only:
• Minimal care
• Custodial care services
• Ambulatory care
• Part-time care services
It does not include institutions that primarily provide for the care and treatment of mental disorders or substance abuse.
Skilled nursing services
Services provided by an R.N. or L.P.N. within the scope of his or her license. Specialist(s)
A physician who practices in any generally accepted medical or surgical sub-specialty.
Specialty care prescription drugs
These are prescription drugs that include self-injectable, injectable, infusion and oral drugs prescribed to address complex, chronic diseases with associated co-morbidities such as:
 Cancer
 Rheumatoid arthritis
 Hemophilia
 Human immunodeficiency virus infection
 Multiple sclerosis
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You can access the list of these specialty care prescription drugs by calling the toll-free Member
Services number on your member ID card or by logging on to your my.aetna.com secure member
website at www.aetna.com. The list also includes biosimilar prescription drugs.
Specialty pharmacy
This is one of a set of network pharmacies designated to fill prescriptions for self-injectable drugs and
specialty care prescription drugs.
Stay
A full-time inpatient confinement for which a room and board charge is made.
Step therapy (Restricted access prescription drugs)
A form of precertification under which certain prescription drugs will be excluded from coverage, unless a first-line therapy drug(s) is used first by you. The list of step-therapy drugs is subject to change by
Aetna or an affiliate. An updated copy of the list of drugs subject to step therapy shall be available upon
request by you or may be accessed on the Aetna website at www.aetna.com/individuals-families/find-a­
medication/leap-plans.html.
Substance abuse
This is a physical or psychological dependency, or both, on a controlled substance or alcohol agent.
These are defined on Axis I in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published
by the American Psychiatric Association. This term does not include conditions that you cannot attribute
to a mental disorder that are a focus of attention or treatment. Or an addiction to nicotine products,
food or caffeine intoxication.
Surgery center
A facility specifically licensed as a freestanding ambulatory surgical facility by applicable state and
federal laws to provide outpatient surgery services. If state law does not specifically provide for
licensure as an ambulatory surgical facility, the facility must meet all Medicare accreditation standards
(even if it does not participate in Medicare).
Surgery or surgical procedures
The diagnosis and treatment of injury, deformity and disease by manual and instrumental means, such
as cutting, abrading, suturing, destruction, ablation, removal, lasering, introduction of a catheter (e.g.,
heart or bladder catheterization) or scope (e.g., colonoscopy or other types of endoscopy), correction of
fracture, reduction of dislocation, application of plaster casts, injection into a joint, injection of
sclerosing solution, or otherwise physically changing body tissues and organs.
Telemedicine
A telephone or internet-based consult with a provider that has contracted with Aetna to offer these
services.
Terminal illness(es)
A medical prognosis that you are not likely to live more than 6-24 months.
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Therapeutic drug class
A group of drugs or medications that have a similar or identical mode of action. Or are used for the
treatment of the same or similar disease or injury.
Transplant
Replacement of solid organs; stem cells; bone marrow or tissue. Transplant Occurrence
Considered to begin at the point of authorization for evaluation for a transplant, and end: (1) 180 days from the date of the transplant; or (2) upon the date you or your covered dependent is discharged from
the hospital or outpatient facility for the admission or visit(s) related to the transplant, whichever is later. Urgent care facility
A facility licensed as a medical facility by applicable state and federal laws to treat an urgent condition.
Urgent condition
An illness or injury that requires prompt medical attention but is not an emergency medical condition.
Walk-in clinic
A free-standing health care facility. Neither of the following should be considered a walk-in clinic:
 An emergency room
 The outpatient department of a hospital
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Discount programs
Discount arrangements
We can offer you discounts on health care related goods or services. Sometimes, other companies
provide these discounted goods and services/ These companies are called “third party service
providers.” These third party service providers may pay us so that they can offer you their services.
Third party service providers are independent contractors. The third party service provider is
responsible for the goods or services they deliver. We are not responsible. But, we have the right to
change or end the arrangements at any time.
These discount arrangements are not insurance/ We don’t pay the third party service providers for the
services they offer. You are responsible for paying for the discounted goods or services.
Wellness and Other Incentives
We may encourage and incent you to access certain medical services, to use online tools that enhance
your coverage and services, and to continue participation as an Aetna member. You and your doctor can
talk about these medical services and decide if they are right for you. We may also encourage and
incent you in connection with participation in a wellness or health improvement program. Incentives
include but are not limited to: modifications to copayment, deductible, or coinsurance amounts;
premium discounts or rebates; contributions to a health savings account; fitness center membership
reimbursement; merchandise; coupons; gift cards; debit cards; or any combination of thereof. The
award of any such incentive shall not depend upon the result of a wellness or health improvement
activity or upon a member's health status.
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Tier 1 network and Tier 2 network coverage under the Aetna LeapSM Everyday – CaroMont Health plan
Schedule of benefits
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Schedule of benefits This schedule of benefits lists the deductibles and copayments/coinsurance, if any, that apply to
the services you receive under this plan. You should review this schedule to become familiar with
your deductibles and copayments/coinsurance and any limits that apply to the services.
How to read your schedule of benefits


You are responsible to pay any deductibles and copayments/coinsurance.
You are responsible for full payment of any health care services you receive that are not
a covered benefit.
 You will pay less cost share when you use a tier 1 network provider. Tier 2 network
providers are available to you but the cost share will be at a higher level when these
providers are used. You may select a tier 1 or tier 2 network provider from the
directory or by logging on to our website at www.aetna.com. You can search our online
directory, www.aetna.com/individuals-families/cb/north-carolina/provider­
search/caromont-health-hpn.html, for names and locations of providers.
 This plan has maximums for specific covered benefits. For example, these could be visit,
day or dollar maximums. They may be combined maximums between or separate
maximums for tier 1 network providers and tier 2 providers unless we state otherwise.
Important note:
All covered benefits are subject to the calendar year deductible and
copayment/coinsurance unless otherwise noted in the schedule of benefits below.
We are here to answer any questions. Contact Member Services by logging onto your
my.aetna.com secure member website at www.aetna.com or calling the number on your ID card.
The coverage described in this schedule of benefits will be provided under !etna Health Inc.’s
HMO policy. This schedule of benefits replaces any schedule of benefits previously in effect under
the HMO policy. Keep this schedule of benefits with your policy.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Plan features
Cost share/Deductible/Maximums
Tier 1 network
Tier 2 network
coverage*
coverage*
Deductible
You have to meet your calendar year deductible before this plan pays for benefits.
Individual
$0
$0
Family
$0
$0
Deductible waiver
The calendar year deductible is waived for all of the following eligible health services:
 Preventive care and wellness
 Family planning services - female contraceptives
Maximum out-of-pocket limit
Maximum out-of-pocket limit per calendar year
Individual
$0
Family
$0
$0
$0
General coverage provisions
This section provides detailed explanations about the:
 Deductible
 Maximum out-of-pocket limits
 Maximums that are listed in this schedule of benefits.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Deductible provisions
Eligible health services that are subject to the deductible include prescription drug eligible
health services provided under the medical plan and the outpatient prescription drug plan.
Eligible health services that apply to the deductible will apply to the deductibles for the tier
2 providers and for the tier 1 network providers.
The deductible may not apply to certain eligible health services. You must pay any applicable
copayments/coinsurance for eligible health services to which the deductible does not apply.
Individual
This is the amount you owe for eligible health services each calendar year before the plan
begins to pay for eligible health services. This calendar year deductible applies separately to
you and each covered dependent. After the amount you pay for eligible health services
reaches the calendar year deductible, this plan will begin to pay for eligible health services for
the rest of the calendar year.
Family
This is the amount you owe for eligible health services each calendar year before the plan
begins to pay for eligible health services. After the amount you pay for eligible health services
reaches this family calendar year deductible, this plan will begin to pay for eligible health
services that you incur for the rest of the calendar year.
To satisfy this family deductible limit for the rest of the calendar year, the following must
happen:
 The combined eligible health services that you and each covered dependent incur towards
the individual calendar year deductibles must reach this family deductible limit in a
calendar year.
When this occurs in a calendar year, the individual calendar year deductibles for you and your
covered dependents will be considered to be met for the rest of the calendar year.
Copayments
Copayment
This is a specified dollar amount or percentage that must be paid by you at the time you
receive eligible health services from either a tier 1 or tier 2 network provider. If Aetna
compensates the network provider on the basis of the reasonable amount, your cost share is
based on this amount.
Coinsurance
The specific percentage you have to pay for a health care service listed in the schedule of
benefits.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Maximum out-of-pocket limit provisions
Eligible health services that are subject to the maximum out-of-pocket limit include
prescription drug eligible health services provided under the medical plan and the outpatient
prescription drug plan.
Individual
Once the amount of the copayments/coinsurance and deductibles you have paid for eligible
health services during the calendar year meets the individual maximum out-of-pocket limit,
this plan will pay 100% of the negotiated charge for covered benefits that apply toward the
limit for the rest of the calendar year for that person.
Family
Once the amount of the copayments/coinsurance and deductibles you or your covered
dependents have paid for eligible health services during the calendar year meets this family
maximum out-of-pocket limit, this plan will pay 100% of the negotiated charge for such
covered benefits that apply toward the limit for the remainder of the calendar year for all
covered family members.
To satisfy this family maximum out-of-pocket limit for the rest of the calendar year, the
following must happen:
 The family maximum out-of-pocket limit is a cumulative maximum out-of-pocket limit for
all family members. The family maximum out-of-pocket limit can be met by a combination
of family members with no single individual within the family contributing more than the
individual maximum out-of-pocket limit amount in a calendar year.
The maximum out-of-pocket limit is the maximum amount you are responsible to pay for
eligible health services during the calendar year. This plan has an individual and family
maximum out-of-pocket limit.
Family
Once the amount of the copayments/coinsurance and deductibles paid during the calendar
year for eligible health services meets this family maximum out-of-pocket limit, this plan will
pay 100% of the family’s covered benefits that apply toward the limit for the rest of the
calendar year.
Certain costs that you incur do not apply toward the maximum out-of-pocket limit. These
include:
 All costs for non-covered services
 Certain other eligible health services in the schedule of benefits
Limit provisions
Eligible health services that apply to the limit will apply to the limits for tier 2 network
providers and for tier 1 network providers.
Calculations; determination of benefits provisions
Your responsibility for the costs of services will be calculated on the basis of when the service
or supply is provided, not when payment is made. Benefits will be pro-rated to account for
treatment or portions of stays that occur in more than one calendar year. Determinations
regarding when benefits are covered are subject to the terms and conditions of the policy.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Eligible
Tier 1 network coverage* Tier 2 network coverage*
health
services
1. Preventive care and wellness
 Routine physical exams – Performed at a physician, PCP office
 Preventive care immunizations – Performed in a facility or at a physician, PCP
office
 Well woman preventive visits – routine gynecological exams
(including pap smears) – Performed at a physician, PCP, obstetrician (OB),
gynecologist (GYN) or OB/GYN office
 Preventive screening and counseling services – Includes obesity and/or
healthy diet counseling, misuse of alcohol and/or drugs, use of tobacco products,
sexually transmitted infection counseling, genetic risk counseling for breast and ovarian
cancer - Office visits
 Routine cancer screenings – applies whether performed at a physician, PCP,
specialist office or facility
 Prenatal care services – provided by an obstetrician (OB), gynecologist (GYN),
and/or OB/GYN
 Comprehensive lactation support and counseling services – Facility or
office visits
 Breast feeding durable medical equipment – Breast pump supplies and
accessories
 Family planning services – female contraceptive counseling services office visit,
devices, voluntary sterilization
Preventive care and
0% coinsurance no deductible
0% coinsurance no deductible
wellness (as described
applies
applies
above)
Preventive care and wellness benefit limitations
Limitations - Child
Limitations - Adult
Subject to any age and visit
limits provided for in the
comprehensive guidelines
supported by the American
Academy of Pediatrics/Bright
Futures/Health Resources and
Services Administration
guidelines for children and
adolescents.
Subject to any age and visit
limits provided for in the
comprehensive guidelines
supported by the American
Academy of Pediatrics/Bright
Futures/Health Resources and
Services Administration
guidelines for children and
adolescents.
For details, contact your
physician.
For details, contact your
physician.
1 visit per calendar year
1 visit per calendar year
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Preventive care immunizations
Limitations
Subject to any age limits
provided for in the
comprehensive guidelines
supported by Advisory
Committee on Immunization
Practices of the Centers for
Disease Control and Prevention.
For details, contact your
physician.
Subject to any age limits
provided for in the
comprehensive guidelines
supported by Advisory
Committee on Immunization
Practices of the Centers for
Disease Control and
Prevention. For details, contact
your physician.
Well woman preventive visits
Routine gynecological exams (including pap smears)
Limitations
Subject to any age limits
provided for in the
comprehensive guidelines
supported by the Health
Resources and Services
Administration.
Subject to any age limits
provided for in the
comprehensive guidelines
supported by the Health
Resources and Services
Administration.
Preventive screening and counseling services: limitations are per calendar year
unless stated
Obesity and/or healthy
diet
Misuse of alcohol and/or
drugs
Use of tobacco products
Sexually transmitted
infection
Genetic risk counseling for
breast and ovarian cancer
Coverage is limited to: age 0-22,
unlimited visits; age 22+, 26
visits every 12 months, of which
up to 10 visits may be used for
healthy diet counseling.
Coverage is limited to 5 visits
every 12 months.
Coverage is limited to 8 visits
every 12 months.
Coverage is limited to 2 visits
every 12 months.
Not subject to any age or
frequency limitations.
Coverage is limited to: age 0­
22, unlimited visits; age 22+, 26
visits every 12 months, of
which up to 10 visits may be
used for healthy diet
counseling.
Coverage is limited to 5 visits
every 12 months.
Coverage is limited to 8 visits
every 12 months.
Coverage is limited to 2 visits
every 12 months.
Not subject to any age or
frequency limitations.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Routine cancer screenings (Please refer to your policy for specific benefit requirements)
Limitations:
Subject to any age; family
history; and frequency
guidelines as set forth in the
most current:
• Evidence-based items that
have in effect a rating of A or B
in the current recommendations
of the United States Preventive
Services Task Force; and
 The comprehensive
guidelines supported by the
Health Resources and Services
Administration.
 Any lung cancer screenings
that exceed the lung cancer
screening maximum above are
covered under the Outpatient
diagnostic testing section.
Subject to any age; family
history; and frequency
guidelines as set forth in the
most current:
• Evidence-based items that
have in effect a rating of A or B
in the current
recommendations of the
United States Preventive
Services Task Force; and
 The comprehensive
guidelines supported by the
Health Resources and Services
Administration.
 Any lung cancer screenings
that exceed the lung cancer
screening maximum above are
covered under the Outpatient
diagnostic testing section.
Comprehensive lactation support and counseling services
Lactation counseling
services maximum visits
per calendar year either in
a group or individual
setting
Coverage is limited to 6 visits*
Coverage is limited to 6 visits*
*Any visits that exceed
the lactation counseling
services maximum are
covered under physician
services office visits.
Breast feeding durable medical equipment
Important note:
You should review the Maternity and related newborn care section. It will give you more
information on coverage levels for maternity care under this plan. See the Breast feeding
durable medical equipment section of the certificate for limitations on breast pump and
supplies.
Family planning services – female contraceptives
Contraceptive counseling
services maximum visits
per calendar year either in
a group or individual
setting
Coverage is limited to 2 visits
Coverage is limited to 2 visits
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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2. Physicians and other health professionals
Physician services
Office hours visits (nonsurgical) non preventive
care
$0 copay
$0 copay
Complex imaging services
performed during: a
physician office visit
Lab work performed
during a physician office
visit
Radiological work
performed during a
physician office visit
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
$0 copay
Not applicable
Telemedicine
Online internet and
telephonic consultations
by a network
Telemedicine provider
Allergy injections
Without physician, PCP or
specialist office
Covered according to the type of Covered according to the type
benefit and the place where the of benefit and the place where
service is received.
the service is received.
Allergy testing and treatment
Performed at a physician,
PCP or specialist office
Covered according to the type of Covered according to the type
benefit and the place where the of benefit and the place where
service is received.
the service is received.
Immunizations when not part of the physical exam
Immunizations when not
part of the physical exam
Covered according to the type of Covered according to the type
benefit and the place where the of benefit and the place where
service is received.
the service is received.
Injectable medications
Performed at a physician,
PCP or specialist office
Covered according to the type of Covered according to the type
benefit and the place where the of benefit and the place where
service is received.
the service is received.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Specialist office visits
Office hours visit (non­
surgical)
Complex imaging services
performed during a
specialist office visit
Lab work performed
during a specialist office
visit
Radiological services
performed during a
specialist office visit
$0 copay
$0 copay
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Physician surgical services
Performed at a physician
or specialist office
$0 copay
$0 copay
Alternatives to physician office visits
Walk-in clinic visits
Walk-In clinic nonemergency visit (includes
coverage for
immunizations.)
Limitations
$0 copay
$0 copay
Subject to any age limits
provided for in the
comprehensive guidelines
supported by Advisory
Committee on Immunization
Practices of the Centers for
Disease Control and Prevention.
Subject to any age limits
provided for in the
comprehensive guidelines
supported by Advisory
Committee on Immunization
Practices of the Centers for
Disease Control and
Prevention.
For details, contact your
physician.
For details, contact your
physician.
Individual screening and counseling services*
Includes obesity and/or healthy diet counseling, use of tobacco products and stress
management services.
Individual screening and
0% coinsurance no deductible
0% coinsurance no deductible
counseling services
applies
applies
Refer to the Preventive care and wellness section earlier in this schedule of benefits for
maximums that may apply to these types of services.
*Important note:
Not all preventive care and stress management services are available at all walk-in clinics. The
types of services offered will vary by the provider and location of the clinic. These services may
also be obtained from a network physician.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Private Duty Nursing
Outpatient private duty
nursing
Limit per calendar year
$0 copay
$0 copay
Coverage is limited to 70 eight hour shifts per calendar year. 1 shift
equals 8 hours.
Eligible health
Tier 1 network coverage*
services
3. Hospital and other facility care
Hospital care
Tier 2 network
coverage*
Inpatient hospital
$0 copay
$0 copay
Alternatives to hospital stays
Outpatient surgery
Performed in hospital
outpatient department
Performed in facility
other than hospital
outpatient department
$0 copay
$0 copay
$0 copay
$0 copay
Home health care and skilled behavioral health services in the home
Outpatient
Visit limits per calendar
year
$0 copay
$0 copay
Coverage is limited to 120 visits per calendar year.
Hospice care
Inpatient facility and
other hospice care
benefits during a stay
Outpatient
$0 copay
$0 copay
$0 copay
$0 copay
Skilled nursing facility
Inpatient facility
Day limit per calendar
year
$0 copay
$0 copay
Coverage is limited to 90 days per calendar year.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Eligible health
Tier 1 network coverage*
services
4. Emergency services and urgent care
Tier 2 network
coverage*
A separate hospital emergency room or urgent care deductible or copayment/coinsurance will
apply for each visit to an emergency room or an urgent care provider.
Hospital emergency
$0 copay
Paid the same as -tier 1
room
network coverage
Non-emergency care in a Not covered
Not covered
hospital emergency room
Important note:
 As out-of-network providers do not have a contract with us the provider may not accept
payment of your cost share, (deductible, copayment and coinsurance), as payment in full.
You may receive a bill for the difference between the amount billed by the provider and the
amount paid by this plan. If the provider bills you for an amount above your cost share, you
are not responsible for paying that amount. You should send the bill to the address listed on
the back of your ID card, and we will resolve any payment dispute with the provider over
that amount. Make sure the member's ID number is on the bill.
 If you are admitted to a hospital as an inpatient right after a visit to an emergency room,
your emergency room copayment/coinsurance will be waived and your inpatient
copayment/coinsurance will apply.
Urgent medical care
$0 copay
$0 copay
at an urgent care facility
Non-urgent use of urgent
care provider at an
urgent fare facility
Not covered
Not covered
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Eligible health
Tier 1 network coverage* Tier 2 network
services
coverage*
5. Pediatric dental care
Limited to covered persons through the end of the month in which the
covered child turns 19
Type A services
Type B services
$0 copay
$0 copay
0% coinsurance after deductible
Type C services
0% coinsurance after deductible
Orthodontic services
0% coinsurance after deductible
0% coinsurance after
deductible
0% coinsurance after
deductible
0% coinsurance after
deductible
$75
Dental emergency
$75
maximum benefit:
The dental emergency maximum benefit is the most the plan will pay for health care services
incurred by a covered person for any one dental emergency.
Dental benefits are subject to the medical plan’s deductibles and maximum out-of-pocket
limits as explained on the schedule of benefits.
Type A Services: Diagnostic and Preventive Care
Visits and images
 Office visit during regular office hours, for oral examination (limited to: 2 visits every
12 months)
 Routine comprehensive or recall examination (limited to: 2 visits every 12 months)
 Comprehensive periodontal evaluation (limited to: 2 visits every 12 months)
 Problem-focused examination (limited to: 2 visits every 12 months)
 Prophylaxis (cleaning) (limited to: 2 treatments per year)
 Topical application of fluoride (limited to: 2 courses every 12 months)
 Topical fluoride varnish (limited to: 2 courses every 12 months)
 Sealants, per tooth (limited to: one application every 3 years for permanent molars)
 Bitewing images (limited to: 2 sets per 12 months)
 Complete image series, including bitewings if medically necessary (limited to: 1 set
every 3 years)
 Panoramic film (limited to: 1 set every 3 years)
 Vertical bitewing images (limited to: 2 sets per year)
 Periapical images
 Intra-oral, occlusal view, maxillary or mandibular
 Emergency palliative treatment per visit
Space maintainers
 Only when needed to preserve space resulting from premature loss of primary teeth.
Includes all adjustments within 6 months after installation.
 Fixed (unilateral or bilateral)
 Removable (unilateral or bilateral)
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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

Re-cementation of space maintainer
Removal of space maintainer
Type B Services: Basic Restorative Care
Visits and images
 Professional visit after hours (payment will be made on the basis of services rendered
or visit, whichever is greater)
 Consultation (by other than the treating provider)
Images and pathology
 Upper or lower jaw, extra-oral
- Therapeutic drug injection, by report
Oral surgery
 Extractions
- Erupted tooth or exposed root
- Coronal remnants
- Surgical removal of erupted tooth/root tip
 Impacted teeth
- Removal of tooth (soft tissue)
 Surgical removal of impacted teeth
- Removal of tooth (partially bony)
- Removal of tooth (completely bony)
 Odontogenic cysts and neoplasms
- Incision and drainage of abscess
- Removal of odontogenic cyst or tumor
 Other surgical procedures
- Alveoplasty, in conjunction with extractions - per quadrant
- Alveoplasty, in conjunction with extractions, 1 to 3 teeth or tooth spaces - per
quadrant
- Alveoplasty, not in conjunction with extraction - per quadrant
- Alveoplasty, not in conjunction with extractions, 1 to 3 teeth or tooth spaces - per
quadrant
- Sialolithotomy: removal of salivary calculus
- Closure of salivary fistula
- Excision of hyperplastic tissue
- Removal of exostosis
- Tooth reimplantation
- Transplantation of tooth or tooth bud
- Closure of oral fistula of maxillary sinus
- Sequestrectomy
- Crown exposure to aid eruption
- Removal of foreign body from soft tissue
- Frenectomy
- Suture of soft tissue injury
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Periodontics
 Occlusal adjustment (other than with an appliance or by restoration)
 Periodontal scaling and root planing, per quadrant (limited to 4 separate quadrants
every 2 years)
 Root planing and scaling per quadrant (limited to: 4 separate quadrants every 2 years)
 Root planing and scaling – 1 to 3 teeth per quadrant (limited to: once per site every 2
years)
 Periodontal maintenance procedures following active therapy (limited to: 2 in 12
months)
 Localized delivery of antimicrobial agents
Endodontics
 Pulp capping
 Pulpotomy
 Pulpal therapy
Restorative dentistry
Excludes inlays, crowns (other than prefabricated stainless steel or resin) and bridges
Multiple restorations in 1 surface will be considered as a single restoration.
 Amalgam restorations
 Resin-based composite restorations (other than for molars)
 Pins
 Pin retention—per tooth, in addition to amalgam or resin restoration
 Crowns (when tooth cannot be restored with a filling material)
 Prefabricated stainless steel
 Prefabricated resin crown (excluding temporary crowns)
 Recementation
- Inlay
- Crown
- Bridge
Prosthodontics
 Dentures and partials
- Office reline
- Laboratory relines
- Special tissue conditioning, per denture
- Rebase, per denture
- Adjustment to denture (more than 6 months after installation)
• Full and partial denture repairs
- Broken dentures, no teeth involved
- Repair cast framework
- Replacing missing or broken teeth, each tooth
- Adding teeth to existing partial denture
o Each tooth
o Each clasp
 Repairs: bridges; partial dentures
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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General anesthesia and intravenous sedation
 Only when medically necessary and only when provided in conjunction with a covered
dental surgical procedure
Type C Services: Major Restorative Care
Periodontics
 Osseous surgery, including flap and closure, 1 to 3 teeth per quadrant (limited to: 1
per site every 3 years)
 Osseous surgery, including flap and closure, (limited to: 1 per quadrant every 3 years)
 Soft tissue graft procedures
 Gingivectomy, per quadrant (limited to: 1 per quadrant every 3 years)
 Gingivectomy, 1 to 3 teeth per quadrant
 Gingival flap procedure - per quadrant (limited to: 1 per quadrant every 3 years)
 Gingival flap procedure – 1 to 3 teeth per quadrant (limited to: 1 per site every 3
years)
 Clinical crown lengthening
 Full mouth debridement (limited to: 1 treatment per lifetime)
Endodontics
 Apexification/recalcification
 Apicoectomy
 Pupal regeneration
 Root canal therapy including medically necessary images:
- Anterior
- Bicuspid
- Molar
 Retreatment of previous root canal therapy including medically necessary images:
- Anterior
- Bicuspid
- Molar
o Root amputation
o Hemisection (including any root removal)
Restorative
 Inlays, onlays, labial veneers and crowns when provided as treatment for decay or
acute traumatic injury and only when teeth cannot be restored with a filling material
or when the tooth is an abutment to a fixed bridge (limited to: 1 per tooth every 5
years)
 Inlays/Onlays (limited to : 1 per tooth every 5 years)
 Crowns (limited to: 1 per tooth every 5 years)
- Resin (limited to: 1 per tooth every 5 years) - Resin with noble metal (limited to: 1 per tooth every 5 years) - Resin with base metal (limited to: 1 per tooth every 5 years)
- Porcelain/ceramic substrate (limited to: 1 per tooth every 5 years) - Porcelain with noble metal (limited to: 1 per tooth every 5 years) - Porcelain with base metal (limited to: 1 per tooth every 5 years)
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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-
-
-
-
Base metal (full cast) (limited to: 1 per tooth every 5 years)
Noble metal (full cast) (limited to: 1 per tooth every 5 years)
Titanium (limited to: 1 per tooth every 5 years)
3/4 cast metallic or porcelain/ceramic (limited to: 1 per tooth every 5 years)
o Post and core
o Core build-up
Prosthodontics
• Installation of dentures and bridges is covered only if needed to replace teeth which
were not abutments to a denture or bridge less than 5 years old
 Replacement of existing bridges or dentures (limited to: 1 every 5 years)
- Bridge abutments (See Inlays/Onlays and Crowns) (limited to: 1 every 5 years)
- Pontics (limited to: 1 every 5 years)
 Base metal (full cast) (limited to: 1 every 5 years)
 Noble metal (full cast) (limited to: 1 every 5 years)
 Porcelain with noble metal (limited to: 1 every 5 years)
 Porcelain with base metal (limited to: 1 every 5 years)
 Resin with noble metal (limited to: 1 every 5 years)
 Resin with base metal (limited to: 1 every 5 years)
 Titanium
 Removable Bridge (unilateral) (limited to: 1 every 5 years)
 One piece casting, chrome cobalt alloy clasp attachment (all types) per unit, including
pontics (limited to: 1 every 5 years)
 Dentures and Partials (Fees for dentures and partial dentures include relines, rebases
and adjustments within 6 months after installation. Fees for relines and rebases
include adjustments within 6 months after installation. Specialized techniques and
characterizations are not eligible.)
 Complete upper denture (limited to: 1 every 5 years)
 Complete lower denture (limited to: 1 every 5 years)
 Immediate upper denture (limited to: 1 every 5 years)
 Immediate lower denture (limited to: 1 every 5 years)
 Partial upper or lower, resin base (including any conventional clasps, rests and teeth)
(limited to: 1 every 5 years)
 Partial upper or lower, cast metal base with resin saddles (including any conventional
clasps, rests and teeth) (limited to: 1 every 5 years)
 Implants (Only if determined as a dental necessity) (limited to: 1 every 5 years)
 Implant supported complete denture, partial denture (limited to: 1 every 5 years)
 Stress breakers
 Interim partial denture (stayplate), anterior only
 Occlusal guard patients age 13 or older
Orthodontic Care
 Medically necessary comprehensive treatment
 Replacement of retainer (limited to: 1 per lifetime)
 Orthodontic waiting period (24 months)
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Eligible health
Tier 1 network coverage*
services
6. Specific conditions
Diabetic equipment, supplies and education
Tier 2 network
coverage*
Diabetic equipment
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
Diabetic supplies
Diabetic education
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
0%, no deductible applies
Family planning services - other
Inpatient services
Voluntary sterilization for
males
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the
type of benefit and the place
where the service is received.
Outpatient services
Voluntary sterilization for
males
Jaw joint disorder treatment
Jaw joint disorder
treatment
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type
of benefit and the place where
the service is received.
Maternity and related newborn care
Inpatient and other
$0 copay
$0 copay
maternity and related
newborn care services
and supplies
For in-network services, any copayment that is collected applies to the delivery and postpartum
care services provided by an OB, GYN, or OB/GYN only. No copayment that is collected applies
to prenatal care services provided by an OB, GYN, or OB/GYN.
See the Prenatal care sections for cost-sharing and maximums that apply to these services.
Delivery services and postpartum care services
Performed in a facility or
at a physician office
Other prenatal care
services
$0 copay
$0 copay
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type
of benefit and the place where
the service is received.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Mental health treatment
Coverage is provided under the same terms, conditions as any other illness.
Inpatient facility and
$0 copay
$0 copay
other inpatient services
and supplies
Residential treatment
Coverage is provided under the same terms, conditions as any other illness.
Inpatient facility and
$0 copay
$0 copay
other inpatient services
and supplies
Mental health treatment
Coverage is provided under the same terms, conditions as any other illness.
Outpatient visits to a
$0 copay
$0 copay
physician or behavioral
health provider
Partial hospitalization treatment (at least 4 hours, but less than 24 hours per day of clinical
treatment)
Intensive outpatient program (at least 2 hours per day and at least 6 hours per week of clinical
treatment)
Substance related disorders treatment
Detoxification
Coverage is provided under the same terms, conditions as any other illness.
Outpatient
$0 copay
$0 copay
Partial hospitalization treatment (at least 4 hours, but less than 24 hours per day of clinical
treatment)
Intensive outpatient program (at least 2 hours per day and at least 6 hours per week of clinical
treatment)
Rehabilitation
Coverage is provided under the same terms, conditions as any other illness.
Inpatient and other
$0 copay
$0 copay
inpatient services and
supplies
Residential treatment
Coverage is provided under the same terms, conditions as any other illness.
Inpatient facility and
$0 copay
$0 copay
other inpatient services
and supplies
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Rehabilitation
Coverage is provided under the same terms, conditions as any other illness.
Outpatient
$0 copay
$0 copay
Partial hospitalization treatment (at least 4 hours, but less than 24 hours per day of clinical
treatment) provided in a facility or program for treatment of substance abuse provided under
the direction of a physician.
Intensive outpatient program (at least 2 hours per day and at least 6 hours per week of clinical
treatment) provided in a facility or program for treatment of substance abuse provided under
the direction of a physician.
Reconstructive breast surgery
Reconstructive breast
surgery
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type
of benefit and the place where
the service is received.
Reconstructive surgery and supplies
Reconstructive surgery
and supplies
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type
of benefit and the place where
the service is received.
Bariatric Surgery
0% coinsurance after deductible
0% coinsurance after
deductible
Eligible health
services
In-network coverage*
Out-of-network
coverage*
Network (IOE facility)
Network (Non-IOE
facility)
Treatment of Obesity
Transplant services facility and non-facility
Inpatient and other
inpatient services and
supplies
Coverage at the innetwork cost share is
limited to IOE only.
Outpatient
Physician services
$0 copay
Not applicable
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Not applicable
Not applicable
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Eligible health
Tier 1 network coverage*
services
Treatment of infertility
Tier 2 network
coverage*
Basic infertility
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type of
benefit and the place where the
service is received.
Eligible health
Tier 1 network coverage*
services
7. Specific therapies and tests
Outpatient diagnostic testing
Diagnostic complex imaging services
Tier 2 network
coverage*
Complex imaging
services
$0 copay
$0 copay
$0 copay
$0 copay
Diagnostic lab work
Lab work
Diagnostic radiological services
X-ray
$0 copay
$0 copay
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type
of benefit and the place where
the service is received.
Chemotherapy
Chemotherapy
Outpatient infusion therapy
Performed in a physician
office or in a person’s
home
Performed in outpatient
facility
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Specialty care prescription drugs
 Performed in a
physician office or in
the home
 Performed at
outpatient facility
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the
type of benefit and the place
where the service is received.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Short-term rehabilitation (outpatient physical, occupational and speech)
therapies combined with habilitation therapy
Short-term cardiac and pulmonary rehabilitation services
Cardiac and pulmonary
rehabilitation
Member cost share based on
where service is received.
Member cost share based on
where service is received.
Outpatient physical therapy
Physical therapy
Visit limit* per calendar
year
$0 copay
$0 copay
Coverage is limited to 35 visits per calendar year for physical
therapy, occupational therapy, speech therapy and spinal
manipulation combined. Rehabilitation and habilitation coverage is
combined.
*A visit is equal to no more than 1 hour of therapy.
Outpatient occupational therapy
Occupational therapy
Visit limit* per calendar
year
$0 copay
$0 copay
Coverage is limited to 35 visits per calendar year for physical
therapy, occupational therapy, speech therapy and spinal
manipulation combined. Rehabilitation and habilitation coverage is
combined.
*A visit is equal to no more than 1 hour of therapy.
Outpatient speech therapy
Speech therapy
Visit limit* per calendar
year
$0 copay
$0 copay
Coverage is limited to 35 visits per calendar year for physical
therapy, occupational therapy, speech therapy and spinal
manipulation combined. Rehabilitation and habilitation coverage is
combined.
*A visit is equal to no more than 1 hour of therapy.
Spinal manipulation
Spinal manipulation
Visit limit per calendar
year
$0 copay
$0 copay
Coverage is limited to 35 visits per calendar year for physical
therapy, occupational therapy, speech therapy and spinal
manipulation combined. Rehabilitation and habilitation coverage is
combined.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Habilitation therapy services
Therapies other than
physical, occupational,
and speech
Visit limit* per calendar
year
$0 copay
$0 copay
Coverage is limited to 35 visits per calendar year for physical
therapy, occupational therapy, speech therapy and spinal
manipulation combined. Rehabilitation and habilitation coverage is
combined.
*A visit is equal to no more than 1 hour of therapy.
Outpatient facility visits
Outpatient
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the
type of benefit and the place
where the service is received.
Eligible health
services
8. Other services
Acupuncture (please
Tier 1 network coverage*
Tier 2 network
coverage*
Not covered
Not covered
$0 copay
$0 copay
$0 copay
$0 copay
refer to the Policy for
limitations)
Ambulance service
Ground ambulance
Air or water ambulance
Clinical trial therapies (experimental or investigational)
Clinical trial therapies
(including routine patient
costs)
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type
of benefit and the place where
the service is received.
Durable medical equipment (DME)
DME
$0 copay
$0 copay
Hearing aids and exams
Hearing aid exams
Hearing aids
One hearing aid per
hearing impaired ear
every 36 months
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type
of benefit and the place where
the service is received.
Covered according to the type
of benefit and the place where
the service is received.
$0 copay
$0 copay
Prosthetic devices
Prosthetic devices
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Vision care
Pediatric vision care
Limited to covered persons through the end of the month in which the
covered child turns 19
Routine vision exams (including refraction)
Performed by an
ophthalmologist or
optometrist
Visit limit per calendar
year
$0 copay
$0 copay
Coverage is limited to 1 exam per calendar year.
Vision care services and supplies
Office visit for fitting of
Not covered
contact lenses
Preferred or non$0 copay
preferred eyeglass
frames, prescription
lenses or prescription
contact lenses.
Number of eyeglass
One set of eyeglass frames
frames per calendar year
Number of prescription
lenses per calendar year
Number of prescription
contact lenses per
calendar year
One pair of prescription lenses
(includes nonconventional prescription
contact lenses and
aphakic lenses prescribed
after cataract surgery)
Non-disposable lenses: one set
Not covered
$0 copay
Daily disposables: up to 3 month supply
Extended wear disposable: up to 6 month supply
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Plan features
Deductible/ Copayment/Coinsurance
Maximums
9. Outpatient prescription drug
Outpatient prescription drug deductible
Prescription drug eligible health services are subject to the deductible under the medical plan.
There is no separate outpatient prescription drug deductible for prescription drug eligible
health services. Eligible health services that are subject to the deductible include prescription
drug eligible health services provided under the medical plan and the prescription drug plan.
Deductible and copayment/coinsurance waiver for risk reducing
breast cancer drugs
The calendar year deductible and the per prescription copayment/coinsurance will not
apply to risk reducing breast cancer prescription drugs when obtained at a network
pharmacy. This means that such risk reducing breast cancer prescription drugs will be paid
at 100%.
Deductible and copayment/coinsurance waiver for contraceptives
The calendar year deductible and the per prescription copayment/coinsurance will not
apply to female contraceptive methods when obtained at a network pharmacy. This
means that such contraceptive methods will be paid at 100% for:
 The following female oral and injectable contraceptives that are generic prescription drugs:
Oral drugs
Injectable drugs
Vaginal rings
Transdermal contraceptive patches
 Female contraceptive devices that are generic devices and brand-name devices
 FDA approved female:
Generic emergency contraceptives
Generic over-the-counter (OTC) emergency contraceptives
The calendar year deductible and the per prescription copayment/coinsurance continue
to apply to prescription drugs that have a generic equivalent, biosimilar or generic
alternative available within the same therapeutic drug class obtained at a network
pharmacy unless you are granted a medical exception.
Deductible and copayment/coinsurance waiver for tobacco cessation
prescription and over-the-counter drugs
The calendar year deductible and the per prescription copayment/coinsurance will not
apply to the first two 90-day treatment regimens for tobacco cessation prescription drugs
and OTC drugs when obtained at a retail network pharmacy.This means that such
prescription drugs and OTC drugs will be paid by the plan at 100%.
Your calendar year deductible and any prescription copayment/coinsurance will apply after
those two regimens have been exhausted.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Eligible health services
In-network coverage
Per prescription copayment/coinsurance
Tier 1 -- generic prescription drugs
For each 30 day supply filled at a retail
pharmacy
$0 copay
For all fills greater than a 30 day supply but no
more than a 90 day supply filled at a retail
pharmacy or mail order pharmacy
$0 copay
Tier 2 -- preferred brand-name prescription drugs
For each fill up to a 30 day supply filled at a
retail pharmacy
For all fills greater than a 30 day supply but no
more than a 90 day supply filled at a retail
pharmacy or mail order pharmacy
$0 copay
$0 copay
Tier 3 -- non-preferred brand-name prescription drugs
For each 30 day supply filled at a retail
pharmacy
$0 copay
For all fills greater than a 30 day supply but no
more than a 90 day supply filled at a retail
pharmacy or mail order pharmacy
$0 copay
Tier 4 -- specialty care prescription drugs (including biosimilar
prescription drugs)
For each 30 day supply filled at a specialty
network pharmacy
$0 copay
Diabetic prescription drugs, supplies and insulin
For each 30 day supply filled at a retail
pharmacy
Paid according to the tier of drug per the
schedule of benefits, above
For all fills greater than a 30 day supply but no
more than a 90 day supply filled at a retail
pharmacy or mail order pharmacy
Paid according to the tier of drug per the
schedule of benefits, above
Orally administered anti-cancer medications
For each 30 day supply filled at a retail
pharmacy or specialty network pharmacy
Paid according to the tier of drug per the
schedule of benefits, above
Outpatient prescription contraceptive drugs and devices
Female contraceptives that are generic
prescription drugs. For each 30 day supply:
 Oral drugs
 Injectable drugs
 Vaginal rings
 Transdermal contraceptive patches
$0 per prescription or refill
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Female contraceptives that are brand-name
prescription drugs. For each 30 day supply:
 Oral drugs
 Injectable drugs
 Vaginal rings*
 Transdermal contraceptive patches
Paid according to the tier of drug per the
schedule of benefits above.
Female contraceptive generic devices and
brand name devices. For each 30 day supply
FDA-approved female generic and brand-name
emergency contraceptives. For each 30 day
supply
FDA-approved female generic and brand-name
over-the-counter emergency contraceptives.
For each 30 day supply
$0 per prescription or refill
*Brand-name vaginal rings covered at 100%
to the extent that a generic is not available
$0 per prescription or refill
$0 per prescription or refill
Preventive care drugs and supplements
For each 30 day supply filled at a retail
$0 per prescription or refill
pharmacy
No calendar year deductible applies
Maximums: Coverage will be subject to any sex, age, medical condition, family history, and
frequency guidelines in the recommendations of the United States Preventive Services Task
Force. For details on the guidelines and the current list of covered preventive care drugs and
supplements, contact Member Services by logging onto your my.aetna.com secure member
website at www.aetna.com or calling the number on your ID card.
Risk reducing breast cancer prescription drugs
For each 30 day supply filled at a retail
$0 per prescription or refill
pharmacy
No calendar year deductible applies
Maximums: Coverage will be subject to any sex, age, medical condition, family history, and
frequency guidelines in the recommendations of the United States Preventive Services Task
Force. For details on the guidelines and the current list of covered risk reducing breast cancer
prescription drugs, contact Member Services by logging onto your my.aetna.com secure
member website at www.aetna.com or calling the number on your ID card.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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Tobacco cessation prescription and over-the-counter drugs
For each 30 day supply filled at a retail
$0 per prescription or refill
pharmacy
No calendar year deductible applies
Maximums:
 Coverage is permitted for two, 90-day treatment regimens only. Any additional treatment
regimens will be paid according to the tier of drug per the schedule of benefits, above.
 Coverage only includes generic drug when a brand-name drug is available.
Coverage will be subject to any sex, age, medical condition, family history, and frequency
guidelines in the recommendations of the United States Preventive Services Task Force. For
details on the guidelines and the current list of covered tobacco cessation Prescription Drugs
and OTC drugs, contact Member Services by logging onto the my.aetna.com secure member
website at www.aetna.com or calling the number on your ID card.
Important note:
See the Outpatient prescription contraceptive drugs and devices, Preventive care drugs and
supplements, and Risk reducing breast cancer prescription drugs sections for more information
on other prescription drug coverage under this plan.
If you or your prescriber requests a covered brand-name prescription drug when a covered
generic prescription drug equivalent is available, you will be responsible for the cost difference
between the generic prescription drug and the brand-name prescription drug, plus the cost
sharing that applies to brand-name prescription drugs. The cost difference that you pay is not
applied towards your calendar year deductible or maximum out-of-pocket limit.
*See How to read your schedule of benefits, important note about your cost sharing and important notice
at the beginning of this schedule of benefits
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