RI 73-052
Aetna Health . . ( formerly Aetna U. S. Healthcare)
2003 http: / / www. aetna. c m/ cust m/ fehbp
A Health Maintenance Organization
Serving: All of Washington, D. C. , North and Central Maryland and Norther Virginia
Enrollme t in this Pla is limited. You must live or work in our
geographic service area to enroll. See page 9 . or requirements. .
2/ 02
This service has Excellent
accreditati n fr m
the NCQA.
See the 2003 Guide .....
m re informati n n
accreditati n.
.........
....
JN1 High Optio Self Only
JN2 High Optio Self and Family
JN4 Standard Option Self Only
JN5 Stadard Optio Self ad Family .
.
For changes
in benefits
see page 10.
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Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.
Sincerely,
Kay Coles James Director
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Notes
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Notice of the Office of Personnel Management's Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
By law, the Office of Personnel Management ( OPM) , which administers the Federal Employees Health Benefits
( FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to
give you this notice to tell you how OPM may use and give out ( disclose ) your personal medical information held by
OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you ( your personal representative) , To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy
is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For
example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities ( such as fraud and abuse investigations) , For research studies that meet all privacy law requirements ( such as for medical research or education) , and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission ( an authorization ) to use or give out your personal medical
information for any purpose that is not set out in this notice. You may take back ( revoke ) your written permission at
any time, except if OPM has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical information.
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Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any
information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay
for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place ( for example, by sending materials to a P. O. Box instead of your home address) .
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may
also call 202-606-0191 and ask for OPM s FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:
Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the
Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal
medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60
days of the change. The privacy practices listed in this notice will be effective April 14, 2003.
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Table of Contents
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Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Stop Health Care Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 1. Facts about this HMO plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 2. How we change for 2003. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 3. How you get care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Identification cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Plan providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
What you must do t get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Circumstances beyond our c ntrol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Services requiring our prior approval. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 .
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
C insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Your catastrophic protecti n ut-of-pocket maximum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
( a) Medical services and supplies provided by physicians and
other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
( b) Surgical and anesthesia services provided by physicians and
other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( c) Services provided by a h spital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
( g) Special features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Services for the deaf and hearing impaired. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
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Inf rmed Health Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Maternity Management Program TM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
National Medical Excellence Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 .
Reciprocity benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Section 6. General exclusions things we don t cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Section 9. Coordinating benefits with other coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
When you have other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
What is Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
TRICARE and CHAMPVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
W rkers Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Other Government agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
When others are responsible for injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Coverage information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
No pre-existing c ndition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Types of coverage available f r you and your family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Children s Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
When benefits and premiums start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
When you l se benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
When FEHB coverage ends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Converting t individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Getting a Certificate of Group Health Plan Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Long Term Care Insurance is still available. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover
7.
7
Page 8
9
......... .
. ... . Introduction/ Pl in Language/ Advisory
Introductio
This brochure describes the benefits you can receive f Aetna Health Inc. , incorp rated in Maryland and licensed t do
business in the District of C lumbia, Maryland and Virginia, under our contract ( CS 1766) with the Office of Personnel
Management ( OPM) , as auth rized by the Federal Employees Health Benefits law.
The address f r Aetna s administrative office is:
Aetna Health Inc.
930 Harvest Drive
Mail Stop U33N
Blue Bell, PA 19422
This brochure is the official statement of benefits. No oral statement can m dify or otherwise affect the benefits,
limitati ns, and exclusi ns f this br chure . It is your resp nsibility to be inf rmed about your health benefits.
If y u are enrolled in this Plan, you are entitled to the benefits described in this br chure. If you are enr lled in Self and
Family c verage, each eligible family member is als entitled t these benefits. Y u d n t have a right t benefits that
were available bef re January 1, 2003, unless these benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes
are summarized on page 10. Rates are shown at the end of this brochure.
Plain Language
. ll FEHB br chures are written in plain language t make them responsive, accessible, and understandable t the
public. For instance,
Except f r necessary technical terms, we use comm n words. For instance, you means the enrollee or family member; we means Aetna Health. .
We limit acronyms t ones y u know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and ther FEHB plans brochures have the same format and similar descriptions to help you c mpare plans.
If y u have comments or suggestions about how t improve the structure of this brochure, let OPM know. Visit OPM s
Rate Us feedback area at www. . opm. g v/ insure
r email OPM at fehbwebcomments@ opm. gov. Y u may also write to
OPM at the Office of Personnel Management, Office
of Insurance Planning and Evaluation Division, 1900 E Street NW,
Washington, DC 20415-3650.
8.
8
Page 9
10
......... .
. .... 5 Introduction/ Plain Language/ Advisory
.
Stop Health Care Fraud!
...... ......................................
.. ........ ......... ................. ................ ... FEHB)
Program premium.
OPM s Office of the Inspect r General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud Here are s me things you can do t prevent fraud:
Be wary of giving your plan identification ( ID) number over the telephone or t people y u do not know, except t your doct r, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits ( EOBs) that you receive from us.
Do n t ask your d ctor to make false entries on certificates, bills or records in order to get us to pay f r an item r service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any informati n, do the f ll wing:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800/ 537-9384 and explain the situation.
If we do not resolve the issue:
.
.
.
.
.
.
Do not maintain as a family member on your p licy:
Your former spouse after a divorce decree or annulment is final ( even if a court order stipulates otherwise) ; or
Your child over age 22 ( unless he/ she is disabled and incapable of self support)
If y u have any questions ab ut the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim t obtain FEHB benefits or try t obtain services for someone who is not an eligible family member or wh is no l nger enrolled in
the Plan.
.
CALL THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washi gton, DC 20415.
9.
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Page 10
11
.
......... .
. ... Section 1
Section 1. Facts about this HMO plan
!. ....... ........... organization ( HMO) . We require you t see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. .. The Plan is s lely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider
directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing
any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the
copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-
Plan providers, you may have to submit claim forms.
You should joi an HMO because you prefer the plan s benefits, not because a particular provider is available.
You cannot cha ge pla s because a provider leaves our Pla . We cannot guarantee that any one physicia ,
hospital, or other provider will be available and/ or remain under contract with us.
...
..
...
.........
Provider Compensation "............ ... ..
....... . . ...#.... ..........#......... ..... to provide the benefits in this brochure. These Plan providers accept a
neg tiated payment fr m us, and y u will only be resp nsible f r your
copayments or coinsurance.
This is a direct contract prepayment Plan, which means that participating
providers are neither agents n r empl yees of the Plan. Rather, they are
independent doct rs and providers who practice in their own offices or
facilities. The Plan arranges with licensed pr viders and h spitals to
provide medical services for both the prevention of disease and the
treatment of illness and injury f r benefits covered under the Plan.
. . Plan providers in our network have agreed t be compensated in
various ways. Many participating primary care physicians ( PCPs) . are
paid by capitation. Under capitation, a physician receives payment for a
patient whether the physician sees the patient that month or not.
. . Specialists, hospitals, primary care physicians and other providers in
the Aetna Health network may also be paid in the following ways:
Per individual service ( fee-f r-service at contracted rates) ,
Per hospital day ( per diem contracted rates) ,
Under other capitation methods ( a certain amount per member, per month) , and
By Integrated Delivery Systems ( IDS ) , Independent Practice Ass ciations ( IPAs ) , Physician Medical Groups ( PMGs ) ,
Physician Hospital Organizations ( PHOs ) , behavioral health
organizations and similar provider organizations or groups that are
paid by Aetna Health Inc. ; the organizati n or group pays the
physician or facility directly. In such arrangements, that group or
organizati n has a financial incentive t control the c sts of providing
care.
You are encouraged to ask your physicians and other providers how
they are compensated for their services, including whether their specific
arrangements include any fi ancial incentives to control costs.
10.
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Page 11
12
.
......... .
. .... $ Section 1
Your Rights %.&...'. ...........................
........ .. ....... ......... ..........(... You
may get inf rmation about
us, our netw rks, pr viders, and facilities. OPM s FEHB website ( www. pm. g v/ insure)
lists the specific types f
inf rmation that we must make available to you. Some f the required inf rmation is listed
below.
........ ...
....
).
........
.... ............. .................( ..)..#..... .. ............ ..........
..#......................
excludes or limits coverage f r some services, including but not limited t cosmetic surgery and experimental
pr cedures. In addition, in order to be c vered, all services, including the location ( type f facility) , duration and costs
of services, must be medically necessary as defined in this Plan and as determined by us. ( See definition on Page 59. )
..........
.................
!. ...........................(... to visit any participating gynecol gist for a routine well-woman exam, including
a Pap smear ( if appropriate) and an unlimited number of visits for gynec logic problems and foll w-up care as
described in your benefits plan. Gynecologists may als refer a woman directly for covered gynec logic services
without the patient having t go back t her participating primary care physician. If your Ob/ Gyn is part f an
Independent Practice Ass ciation ( IPA) , a Physician Medical Group ( PMG) or a similar organization, covered care must
be coordinated through the IPA, the PMG or the similar organization. .
.................
.........
.
.............#...... ..(...
....................
....*....#............................... ......... ......#..........(....
and/ r substance abuse) are managed by an independently c ntracted organization. This organization makes initial
coverage determinations and c rdinates referrals; any behavi ral health care referrals will generally be made to
providers affiliated with the organization, unless your needs for covered services extend beyond the capability f the
affiliated pr viders. You can receive inf rmation regarding the appr priate way t access the behavi ral health care
services that are covered under your specific plan by calling Member Services at 1-800/ 537-9384. As with other
coverage determinations, you may appeal behavi ral health care coverage decisions in accordance with the provisions
of your Plan.
..............
".............. .....
................
............. ..... .. are recommended or provided by health
professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that
the recommended services and supplies are n t covered benefits, you will be notified. If y u wish to appeal such
determination, you may then contact us t seek a review of the determinati n.
Authorizatio
).... .....
............. ........... ......... ...'. ......... +.. ...( ............. ... ..... .......
.....(.... ...
under this Plan.
...................
We have developed a patient management program t assist in determining what health care services are covered under
the health plan and the extent f such coverage. The program assists members in receiving the appropriate health care
and maximizing coverage for those health care services.
Only medical directors make decisions denying coverage f r services for reas ns of medical necessity. Coverage denial
letters delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal
process. .
Our patient management staff uses national guidelines and resources to guide the precertificati n, concurrent review and
retr spective review pr cesses. Using the inf rmation btained fr m pr viders, patient management staff utilizes
Milliman & Robertson Care Guidelines ( M& R Care Guidelines ) when conducting concurrent review. If there are no
applicable M& R Care Guidelines, patient management staff utilizes InterQual ISD criteria. When applicable, Medicare
National Coverage Decisions are foll wed for Medicare managed care members. To the extent certain patient
management functi ns are delegated to integrated delivery systems, independent practice ass ciations or other provider
gr ups ( Delegates ) , such Delegates utilize criteria that they deem appr priate.
11.
11
Page 12
13
2003 Aetna Health . 8 . ection 1 .
.
. Precertification . Certain health care services, such as hospitalization or outpatient surgery,
require precertification by us to ensure coverage. When a member is to
obtain services requiring precertification through a Plan provider, thi
provider should precertify tho e services prior to treatment.
Concurrent Review . The concurrent review proces as e e the neces ity for continued stay, level of care, and quality of care for members receiving inpatient services.
All inpatient services extending beyond the initial certification period will
require Concurrent Review.
Discharge Planning .. Di charge planning may be initiated at any stage of the patient management proces and begins immediately upon identification of post-
di charge needs during precertification or concurrent review. The
di charge plan may include initiation of a variety of ervices/ benefit to be
utilized by the member upon discharge from an inpatient stay.
Retrospective Record Review . ......... ...
...... .... .. record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action
based on quality or utilization issues, and review all appeals of inpatient
concurrent review deci ions for coverage and payment of health care
ervices. Our effort to manage the services provided to members includes
the retro pective review of claim submitted for payment, and of medical
records submitted for potential quality and utilization concern .
Member Services
Representatives from Member Services are trained to an wer your questions and to as i t you in using the Aetna Health
plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free number on the
card when you need to:
Ask questions about benefit and coverage.
Notify us of changes in your name, addres or telephone number.
Change your primary care phy ician or office.
Obtain information about how to file a grievance or an appeal.
Confidentiality
We protect the privacy of confidential Plan member medical information. We contractually require that participating
providers keep member information confidential in accordance with applicable laws. Furthermore, you have the right to
acces your medical records from participating providers, at any time. Aetna Health ( including its affiliates and
authorized agents, collectively ( Aetna Health ) and participating providers require acces to member medical
information for a number of important and appropriate purposes, including claims payment, fraud prevention,
coordination of care, data collection, performance measurement, fulfilling state and federal requirements, quality
management, utilization review, research and accreditation activities, preventive health, early detection and disease
management programs. Accordingly, for these purpo e , members authorize the sharing of member medical information
about themselves and their dependent between Aetna Health and Plan providers and health delivery y tems.
Protecting the privacy of member health information i a top priority at Aetna. When contacting us about thi FEHB
Program Brochure or for help with other questions, please be prepared to provide your or your family member s name,
member ID ( or Social Security Number) , and date of birth.
If you want more information about us, call 1-800/ 537-9384, or write to 930 Harvest Drive, Mail Stop U33N, Blue Bell,
PA 19422. You may al o contact u by fax at 215/ 775-5246 or vi it our web ite at www. aetna. com/ cu tom/ fehbp.
12.
12
Page 13
14
......... .
. .... 9 Section 1
.......
....
!......... .... ......#. .........
in or work in our service area. This is where our providers practice. Our service
area is:
.....".#.
.......$. .
In Maryland , the counties of Anne Arundel, Baltim re, Baltim re City, Calvert, Carr ll, Cecil, Charles, Frederick,
Harford, Howard, Kent, Montgomery, Prince George s, Queen Anne s, St. Mary s, Talbot, Washington, Wicomico and
Worcester.
In Virginia #.......... ......... .....#.).... ..#... ...-#....'. ..#.. .../.....#.0.... L uisa, Prince William,
Sp tsylvania, Staff rd and Westm reland; plus the cities of Alexandria, Fairfax, Falls Church, Fredericksburg,
Manassas and Manassas Park.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we
will pay nly f r emergency care benefits. We will n t pay f r any other health care services out of our service area
unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents
live out of the area ( for example, if your child goes to college in another state) , you should consider enrolling in a fee-
f r-service plan or an HMO that has agreements with affiliates in other areas. If y u or a family member m ve, y u d
not have t wait until Open Season to change plans. Contact your employing or retirement office.
13.
13
Page 14
15
......... .
. ... 12 . ........
Section 2. How we change for 2003
,......... ...................... .. ...3... ....... ............ . ................(.... ............#.......4... ...5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not sh wn here is a
clarification that does n t change benefits.
....... wide changes
..6.. ..........%.. ................&.........7....
.. ...... .... .. ........
A section on the Children s Equity Act describes when an employee is required t maintain Self and Family
coverage.
Program informati n on TRICARE and CHAMPVA explains how annuitants r former spouses may suspend their
FEHB Program enrollment.
Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan
Your share f the n n-p stal premium f r High Option will increase by 4.4% for Self Only and decrease by 2.0% for Self and Family. Your share of the n n-p stal premium f r Standard Option will increase by 10. 3% for Self
Only and increase by 10.3% for Self and Family.
Benefit changes under both High and Standard Options:
We increased the copay t $ 100 per visit for emergency care in the outpatient department of a hospital or at an urgent care center, both within and outside the service area. ( Section 5( d) )
We increased the copay t $ 25 per 30-day supply for brand name formulary prescripti n drugs. ( Section 5( f) )
We increased the copay t $ 50 per 31-day up to a 90-day supply f r brand name formulary prescripti n drugs. ( Section 5( f) )
We changed the copay t $ 40 per 30-day supply for non-formulary prescription drugs. ( Section 5( f) )
We changed the copay t $ 80 for a 31-day up to a 90-day supply of non-formulary prescription drugs. ( Section 5( f) )
We increased the copay t $ 25 per vial of Depo Provera. ( Section 5( f) )
We increased the copay t $ 25 for one diaphragm per year. ( Section 5( f) )
We now exclude benefits for travel related drugs including, but not limited t , anti-malarial drugs. ( Section 5( f) )
We now provide twenty visits per condition per member per calendar year for physical, pulmonary, occupational, and speech therapies. ( Section 5( a) )
Habilitative services are now covered for children under age 19 with congenital or genetic birth defects including, but not limited to, autism or an autism spectrum dis rder, and cerebral palsy. ( Section 5( a) )
Be efit changes u der High Optio :
We increased the inpatient hospital per admission copay t $ 150 per day up t a maximum f 3 days, or $ 450, for both Medical and Mental Health/ Substance Abuse confinements. ( Section 5( c) )
We increased the copay t $ 125 for outpatient hospital or ambulatory surgical center care. ( Section 5( c) )
Benefit changes under Standard Option:
We increased the inpatient hospital per admission copay t $ 250 per day up to a maximum of 3 days, or $ 750, for both Medical and Mental Health/ Substance Abuse confinements. ( Section 5( c) )
We increased the copay t $ 200 for outpatient hospital or ambulatory surgical center care. ( Section 5( c) )
14.
14
Page 15
16
......... .
. ... 11 Section 3
Section 3. How you get care
Identification cards "... ........ ...... .... . ... ...*.,8........... ...........9... should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, r fill a
prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election F rm, SF-2809, your health
benefits enrollment confirmation ( for annuitants) , or your Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, r if you need replacement cards, call us at
1-800/ 537-9384 . r write to us at Aetna Health Inc. , 1425 Union Meeting
R ad, P. O. Box 1125, Blue Bell, PA 19422. You may als request
replacement cards through our website at www. aetna. com/ custom/ fehbp.
Where you get covered care You get care fr m Plan providers and Plan facilities. You will only pay copayments or coinsurance, and you will n t have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards. .
We list Plan providers in the provider directory, which we update
periodically. The most current informati n on our Plan providers is als
on our website at www. aetna. com/ custom/ fehbp
under DocFind.
To ensure covered services, you must n tify Member Services at
1-800/ 537-9384 of your primary care physician selection.
Plan facilities Plan facilities are h spitals and ther facilities in our service area that we contract with to provide covered services to our members. We list
these facilities in the pr vider directory, which we update periodically.
The m st current inf rmation n ur Plan facilities is also n ur
website at www. aetna. com/ custom/ fehbp.
What you must do to get
covered care
It depends on the type of care you need. First, you and each family
member must choose a primary care physician. This decisi n is
important since your primary care physician provides or arranges for
most of your health care. You must select a Plan provider who is located
in your service area as defined by your enrollment code.
Primary care Your primary care physician can be a general practitioner, family practitioner, internist or pediatrician. Your primary care physician will
provide or coordinate most of your health care, r give you a referral t
see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us or visit our website. We will change
your primary care physician t a newly-selected primary care physician.
Specialty care Your primary care physician will refer y u to a specialist f r needed care. If you need laboratory, radi logical and physical therapy services,
your primary care physician must refer you to certain plan providers. If
you need mental health or substance abuse care, you may call your
primary care physician or the behavioral health vendor number on the
front of your ID card. Your primary care physician may refer you to
any participating specialist for other specialty care. When you receive a
15.
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Page 16
17
2003 Aetna Health 12 . Section 3
.
referral from your primary care physician, you must return to the
primary care physician after the consultation, unless your rimary care
physician authorized a certain number of visits without additional
referrals. The rimary care physician must provide or authorize all
follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see a
Plan gynecologist, ( within an IPA, you must see an IPA-approved
gynecologist) , for a routine well-woman exam, including a ap smear ( if
appro riate) and an unlimited number of visits for gynecological
problems and follow-up care as described in your benefit plan without a
referral. You may also see a Plan mental health provider, a Plan vision
specialist, a Plan dentist, or a Plan Certified Nurse Midwife for
obstetrical care without a referral.
Here are other things you should know about s ecialty care:
If you need to see a s ecialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will develop a treatment lan that allows you to see your specialist
for a certain number of visits without additional referrals. Your
rimary care physician will use our criteria when creating your
treatment plan ( the physician may have to get an authorization or
approval beforehand) .
If you are seeing a s ecialist when you enroll in our Plan, talk to your rimary care physician. Your primary care physician will
decide what treatment you need. If he or she decides to refer you to
a s ecialist, ask if you can see your current specialist. If your
current specialist does not articipate with us, you must receive
treatment from a specialist who does. Generally, we will not ay for
you to see a s ecialist who does not partici ate with our Plan.
If you are seeing a s ecialist and your specialist leaves the Plan, call your rimary care physician, who will arrange for you to see
another s ecialist. You may receive services from your current
s ecialist until we can make arrangements for you to see someone
else.
If you have a chronic or disabling condition and lose access to your s ecialist because we:
Terminate our contract with your specialist for other than cause; or
Drop out of the Federal Employees Health Benefits ( FEHB) Program and you enroll in another FEHB Plan; or
Reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for u to 90 days
after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days.
16.
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Page 17
18
2003 Aetna Health 13 Section 3
..
!.... care 9........... ... ........ . . .. or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or ther type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our cust mer service department immediately at 1-800/ 537-9384. If you
are new to the FEHB Pr gram, we will arrange f r you to receive care.
If y u changed fr m an ther FEHB plan to us, your f rmer plan will pay
f r the h spital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only t the benefits of the hospitalized person.
....... .....
......
our control
;.......... ...-...... ... .. ...........#.................. .......#....
may have to delay your services or we may be unable t provide them. In
that case, we will make all reasonable eff rts to pr vide you with the
necessary care.
........
.........
...
prior approval
9...... ... ........ . . ............. . .......... ...............
.....
F r certain services, however, your physician must obtain approval from
us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.
We call this review and appr val process precertification.
%.........(.. .......
............ .....
............
For artificial insemination you must contact the Infertility Case Manager at 1-800/ 575-5999;
You must obtain precertification from your primary care d ctor and Aetna Health . r covered f llow-up care with n nparticipating
providers; and
You must contact Cust mer Service at 1-800/ 537-9384 or call the behavioral health contractor for information on precertification
before you have mental health and substance abuse services.
Your Plan physicia must obtain approval for certain services such as
h spitalization and the f llowing services:
Your Plan physician must obtain approval for surgical treatment of m rbid besity;
F r select outpatient surgery;
For inpatient confinements, skilled nursing facilities, rehabilitation facilities and inpatient h spice;
F r covered transplant surgery;
17.
17
Page 18
19
......... .
. ... 1. . ........
.
When full-time skilled nursing care is necessary in an extended care facility;
F r non-emergent ambulance transportation service;
For certain drugs before they can be prescribed;
F r growth hormone therapy treatment;
For penile implants;
For all home health care services; and
F r certain outpatient imaging studies such as CT scans, MRIs, and MRAs.
%...........!..
..... ......(.. .......
............ ......(...... ....
equipment. Members must call 1-800/ 537-9384 f r authorization.
18.
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Page 19
20
......... .
. ... 36 . Section 4
.
Section 4. Your costs for covered services
.
:..................................
.....:.............. (.......
Copayments A copayment is a fixed amount of money you pay t the pr vider, facility, pharmacy, etc. , when you receive services.
Example: When you see your primary care physician you pay a copayment
of $ 15 per office visit or $ 20 when you see a participating specialist for
High Option and $ 20 per office visit or $ 25 when you see a participating
specialist f r Standard Option.
Deductible We do not have a deductible.
Note: If you change plans during open season, you do n t have to start a
new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the
year, you must begin a new deductible under your new plan.
Coinsura ce Coinsurance is the . percentage f our neg tiated fee that you must pay for your care. .
Example: In ur Plan, you pay 50% of ur allowance f r infertility
services and drugs t treat sexual dysfuncti n.
Your catastrophic protection
out-of-pocket maximum for
copayments and coi surance
...... ........ ............ ........ total $ 1, 500 per person or $ 3,000
per family enrollment in any calendar year, you do not have t pay any
more for covered services. However, copayments and coinsurance for the
foll wing services do not count toward your catastr phic protecti n . out-
of-pocket maximum, and you must continue t pay copayments and
coinsurance f r these services:
Prescription drugs
Dental services
Infertility services
Be sure to keep accurate records of your copayments and coinsurance
since you are responsible for informing us when you reach the maximum.
19.
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Page 20
21
......... .
. ... 1 Section 5 .
Section 5. Benefits OVERVIEW ( See page 10 for how our benefits changed this year and page 67 for a be efits summary. )
NOTE ..!. ..(.... ....... ... ...
.... ......(.... ..................... ........... .... ..........<.... ... ......
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
foll wing subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at
1-800/ 537-9384 or at our website at www. aetna. com/ custom/ fehbp.
( a) Medical services and supplies provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Diagnostic and treatment services Speech therapy
Lab, X-ray, and other diagnostic tests Hearing services ( testing, treatment, and supplies)
Preventive care, adult Vision services ( testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices
Family planning Durable medical equipment ( DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical, pulmonary and occupational therapies Educational classes and programs
Habilitative therapy
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Surgical procedures Organ/ tissue transplants
Reconstructive surgery Anesthesia
Oral and maxillofacial surgery
( c) Services provided by a h spital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Inpatient hospital Hospice care
Outpatient hospital or ambulatory surgical center Ambulance
Extended care benefits/ skilled nursing care facility benefits
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Medical emergency Ambulance
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
( g) Special features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Services for deaf and hearing-impaired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Informed Health Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Maternity Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
National Medical Excellence Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Reciprocity Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
20.
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Page 21
22
2003 Aetna Health 17 Section 5( a)
Section 5 ( a) . Medical services and supplies provided by physicians and other health care professionals
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
Benefit Description
High Option
You pay
Standard Option
You Pay
Diagnostic and treatment services
Professional services of physicians
In physician s office
Office medical consultations
Second surgical or medical opinion
Initial examination of a newborn child covered
under a family enrollment
$ 15 per primary care
physician ( PCP) visit
$ 20 per specialist visit
$ 20 per primary care
physician ( PCP) visit
$ 25 per specialist visit
Professional services of physicians
In an urgent care center for routine services
During a hospital stay
In a skilled nursing facility
$ 15 per PCP visit
$ 20 per specialist visit
$ 20 per PCP visit
$ 25 per specialist visit
At home $ 20 per PCP visit
$ 25 per specialist visit
$ 25 per PCP visit
$ 30 per specialist visit
At home visits by nurses and health aides Nothing Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive
these services during
your office visit;
otherwise, $ 15 per
PCP visit, $ 20 per
specialist visit
Nothing if you receive
these services during
your office visit;
otherwise, $ 20 per
PCP visit, $ 25 per
specialist visit
21.
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Page 22
23
......... .
. ... 1> ......... ..
Preventive care, adult
High Optio
You pay
Standard Option
You pay
Routine screenings, such as:
Total Blood Cholesterol
C lorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years
starting at age 50
Routine Pr state Specific Antigen ( PSA ) ...... one annually for men age 40 and older
Routine Pap test
.&' ..6...... ................. if performed on the
same day as the office visit
Routine mammogram covered for women age 35 and
lder, as f llows:
From age 35 through 39, one during this five year peri d
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years.
.&' : There is no copay for a routine mammogram. If,
however, it is performed in c njunction with an office visit,
the PCP or specialist copay would apply.
$ 15 per PCP visit
$ 20 per specialist visit
Nothing if provided
during the office visit
$ 20 per PCP visit
$ 25 per specialist visit
Nothing if provided
during the office visit
Routine immunizations limited to:
Tetanus-diphtheria ( Td) bo ster once every 10 years, ages 19 and over ( except as provided for
under Childhood immunizati ns)
Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over
Nothing if provided
during the office visit
Nothing if provided
during the office visit
Not covered:
Physical exams required for obtaining or continuing employment or insurance, ttending schools or
camp, or travel.
Immunizations nd boosters for travel or work-rel ted exposure. .
All charges All charges
.
22.
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Page 23
24
.
2003 Aetna Health 19 Section 5( a)
Preventive care, childre
High Optio
You pay
Standard Option
You pay .
Childhood immunizations recommended by the American Academy of Pediatrics Nothing Nothing
Well-child visits f r r utine examinations, immunizations and care ( up t age 22) $ 15 per PCP visit $ 20 per specialist visit $ 20 per PCP visit $ 25 per specialist visit
Examinations, such as:
Eye exams through age 17 to determine the need for vision c rrecti n.
Ear exams through age 17 t determine the need for hearing c rrection
Examinations done on the day of immunizations ( up t age 22)
$ 15 per PCP visit
$ 20 per specialist visit
$ 20 per PCP visit
$ 25 per specialist visit
Maternity care
C mplete maternity ( obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
NOTE : Here are some things to keep in mind:
You do not need t precertify your normal delivery; see bel w for other circumstances, such as extended
stays for you or your baby.
You may remain in the hospital up t 48 hours after a regular delivery and 96 hours after a cesarean
delivery. We will cover an extended inpatient stay if
your Physician determines it is medically necessary.
We cover routine nursery care of the newborn child during the covered porti n of the mother s stay. We
will cover ther care of an infant wh requires n n-routine
treatment only if we cover the infant under a
Self and Family enrollment. Surgical benefits, not
Maternity benefits, apply to circumcision.
We pay hospitalization and surgeon services ( delivery) the same as f r illness and injury. See
Hospital benefits ( Section 5c) and Surgery benefits
( Section 5b) ..
?15.......... ....
PCP visit only
or $ 20 for the
first specialist
visit only
$ 20 f r the first
PCP visit only
or $ 25 for the
first specialist
visit only
............ Routine sonogr ms to determine fetal age, size or sex, and home births. All charges All charges
23.
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Page 24
25
2003 Aetna Health 20 Section 5( a) .
Family planning
High Option
You pay
Standard Option
You pay
A range of voluntary fami y planning services, limited to:
Voluntary sterilization ( see urgical procedures . Section 5( b) )
Surgically implanted contraceptives
Injectable contraceptive drugs, such as Depo Provera
Intrauterine devices ( IUDs)
Diaphragms
N TE: We cover oral contraceptives and Depo Provera
under the prescription drug benefit.
$ 15 per PCP visit
$ 20 per specialist
visit
$ 20 per PCP visit
$ 25 per specialist
visit
Not covered: reversal of voluntary surgical sterilization,
genetic counseling
All charges All charges
Infertility services .
Infertility is defined as the inability to conceive after 12
months of unprotected intravaginal sexual relations ( or
12 cycles of artificial insemination) for women under
age 35 and 6 months of unprotected intravaginal sexual
relations ( or 6 cycles of artificial insemination) for
women age 35 and over.
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination ( ( IVI)
intracervical insemination ( ( ICI)
intrauterine inseminantion ( IUI)
.... for 6 cycles. Artificial
insemination must be authorized. You must contact the
Infertility Case Manager at 1-800/ 575-5999. You must
use our select network of participating Plan infertility
providers. .
Fertility drugs ....
: We cover oral fertility drugs under the
prescription drug benefit. .
In vitro fertilization is a covered benefit when the
following criteria are met:
Your oocytes are fertilized with your spouse s sperm
You and your spouse have a history of infertility of at least 2 years duration
50% of al
charges
50% of al
charges
Infertility services Continued on the next page
24.
24
Page 25
26
2003 Aetna Health 21 Section 5( a) .
Infertility servi es ( Continued) .
High Option
You pay .
Standard Option
You pay
Your infertility is associated with endometriosis, exposure in-utero to diethylstilbestrol ( DES) ,
blockage of, or surgical removal of, one or both
fal opian tubes, or abnormal male factors, including
oligospermia contributing to the infertility
You have been unable to attain a successful pregnancy through a less cost y treatment that is
covered by the P an
NOTE: . In vitro fertilization is limited to a maximum
ifetime benefit of $ 100,000. This includes the cost of
fertility drugs. We cover oral fertility drugs under the
prescription drug benefit. Injectab e fertility drugs are
covered on y for in vitro fertilization. .
50% of al
charges .
50% of al
charges .
Not covered:
Infertility services after reversal of voluntary sterilization of either partner or when the woman
has had a hysterectomy
Infertility treatment when the FSH level is greater that 19 mIU/ ml
Cost of donor sperm and donor eggs
Assisted Reproductive Technology ( ART) procedures not shown, such as embryo transfer ( frozen) , GIFT,
ZIFT, sex selection, surrogacy, gene therapy,
gestational carriers, cryopreservation, and any
other services and supplies related to the non-covered
ART procedures
Charges associated with care of the donor, such as those required for donor egg retrievals or transfers
Charges associated with cryopreservation
Charges associated with a gestational carrier program or for the member or the gestational
carrier
Home ovulation prediction kits
Drugs related to the treatment of non-covered benefits or related to the treatment of infertility that
are not medically necessary based on current
medical standards; including, but not limited to,
GnRH agonists, IVIG; and injectable fertility
medications not used with in vitro fertilization
Charges associated with a frozen embryo transfer including thawing charges
Reversal of voluntary, surgically induced sterility
All charges All charges
25.
25
Page 26
27
.
2003 Aetna Health 22 Section 5( a)
Allergy care
High Optio
You pay
Standard Option
You pay
!... ...... treatment
Allergy injection
.&'( .9..... ......... ..(....... .................
visit. Each visit to a nurse for injection only, you pay
nothing )
$ 15 per PCP visit
$ 20 per specialist
visit, nothing f r a
visit to a nurse
$ 20 per PCP visit
$ 25 per specialist
visit, nothing f r a
visit to a nurse
Allergy serum Nothing Nothing
food testing and sublingual
llergy desensitization .
All charges ...... ....
Treatment therapies .
Chemotherapy and radiation therapy
.&' : High dose chemotherapy in ass ciation with
aut logous bone marr w transplants are limited t those
transplants listed under Organ/ Tissue Transplants on
page 30.
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous ( IV) Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy ( GHT)
.&'( Growth hormone is covered under Medical
Benefits, office copay applies.
.&'( We will only cover GHT when we preauth rize
the treatment. Call 1-800/ 245-1206 for preauthorization.
We will ask you to submit inf rmation that establishes
that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise,
we will only cover GHT services fr m the date you
submit the information. If y u do n t ask or if we
determine GHT is n t medically necessary, we will n t
cover the GHT r related services and supplies. See
........ our prior approval . ..4... ...@
$ 20 per
specialist visit
?:5.....
specialist visit .
26.
26
Page 27
28
......... .
. ... :@ ........ ..
.
therapies
High Optio
You pay
Standard Option
You pay
!. visits per condition . .......(... calendar year for the services of each of the following:
Qualified physical therapists
Occupational therapists
Pulm nary rehabilitation therapists .&' ..%...... ........... is limited to services
that assist the member to achieve and maintain self-
care and impr ved functioning in ther activities of
daily living. Inpatient rehabilitation is covered under
Hospital/ Extended Care Benefits.
Cardiac rehabilitation f llowing angi plasty, cardiovascular surgery, congestive heart failure or a
myocardial infarction is provided for up to 3 visits a
week for a total of 18 visits.
Physical therapy to treat temp romandibular joint ( TMJ) dysfuncti n syndrome
$ 20 per visit,
nothing during a
covered inpatient
admission
$ 25 per visit,
nothing during a
covered inpatient
admission
............
Long-term rehabilitative therapy
All charges ...... .... .
Habilitative therapy .
Habilitative services for children under age 19 with congenital r genetic birth defects including, but not
limited to, autism r an autism spectrum disorder,
and cerebral palsy. Treatment is provided t enhance
the child' s ability to function. Services include
occupational therapy, physical therapy and speech
therapy.
.&'( No day r visit limit applies.
$ 20 per specialist
visit
$ 25 per specialist
visit
Speech therapy
Twenty visits per condition per member per calendar year $ 20 per visit, nothing during a
covered inpatient
admission
$ 25 per visit,
nothing during a
covered inpatient
admission
27.
27
Page 28
29
......... .
. ... :. ......... ..
.......
........ ( testing, treatment, and
supplies)
High Optio
You pay
Standard Option
You pay
).
............ .... ........ .......... .... . necessary treatment for hearing problems $ 15 per PCP visit $ 20 per specialist
visit
$ 20 per PCP visit
$ 25 per specialist
visit
For min r children, hearing aids, testing, fitting and the examination for them All charges over $ 1,400 every
36-month period
All charges over
$ 1,400 every
36-month period
............
All other hearing testing not medically necess ry
All charges All charges
".....
........ ( testing, treatment, and
supplies)
.
Treatment of eye diseases and injury $ 15 per PCP visit $ 20 per specialist
visit
$ 20 per PCP visit
$ 25 per specialist
visit
C rrective eyeglasses and frames or contact lenses ( hard or soft) per 24 month period. All charges over $ 100 All charges over $ 100
Routine eye refracti n based n the foll wing schedule:
If member wears eyeglasses or contact lenses: :
Age 1 through 18 once every 12--month period
Age 19 and over once every 24--month peri d
If member does not wear eyeglasses or contact
lenses:
To age 45 once every 36--month period
Age 45 and over once every 24--month peri d
.&'( children ...... ...-........
children
$ 20 per specialist
visit
$ 25 per specialist
visit
.............
%.............. .........
Eye exercises
Radial keratotomy, including related procedures designed to surgically correct refr ctive errors .
All charges All charges
28.
28
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30
.
......... .
. ... :5 ......... ..
.
Foot care
High Optio
You pay .
. ......
.. ...
You pay
A... .................. ................
..................
metabolic or peripheral vascular disease, such as diabetes.
See Orthopedic and prosthetic devices for more
inf rmation.
$ 15 per PCP visit
$ 20 per specialist
visit
$ 20 per PCP visit
$ 25 per specialist
visit
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toen ils, and similar routine
treatment of conditions of the foot, except as stated
above
Treatment of weak, strained or fl t feet or bunions or spurs; and of any instability, imbalance or
subluxation of the foot ( unless the treatment is by
open manipulation or fixation)
Foot orthotics
Podi tric inserts
All charges All charges
.. ......
...
.... . ..
....... .
%....... ....
... such as braces and prosthetic devices such as artificial limbs and eyes
Externally worn breast prostheses and surgical bras, including necessary replacements, following a
mastectomy
Internal pr sthetic devices, such as artificial joints, pacemakers, cochlear implants, penile implants,
defibrillator, and surgically implanted breast implant
foll wing mastectomy, and lenses foll wing cataract
removal. Note: See 5( b) for c verage of the surgery
to insert the device.
Corrective orthopedic appliances f r non-dental treatment of temp romandibular joint ( TMJ) pain
dysfuncti n syndrome.
.&' ..).
...... ............ ......................
due to growth r n rmal wear and tear.
Nothing Nothing
Hair prosthesis for hair loss resulting from radiation therapy or chem therapy Nothing up to Plan lifetime
maximum of
$ 350; all charges
over $ 350
Nothing up to
Plan lifetime
maximum of
$ 350; all charges
over $ 350
Orthopedic and prosthetic devices !.................."..# ..
29.
29
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31
.
2003 Aetna Health 26 Section 5( a)
.. ......
...
.... . ..
.......
.........
.
High Optio
You pay .
. ......
.. ...
You pay
............
Orthopedic and corrective shoes not att ched to a covered br ce
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacr l supports
All charges All charges
#......
.......
........ ( DME) .
A.............. including replacement, repair and
adjustment, of durable medical equipment prescribed by
your Plan Physician such as xygen equipment. Under
this benefit, we als cover:
Hospital beds;
Wheelchairs ( motorized wheelchairs must be preauthorized) ;
Crutches;
Walkers; and
Insulin pumps.
.&'( .4....,&.... ...'. .......... . ... .. by you
or your physician.
Nothing Nothing
.............
&. .........'..... .....##........
Bathroom equipment such s bathtub seats, benches, r ils and lifts
Home modifications such s stairglides, elevators, and wheelchair r mps
All charges All charges
....
...
........ .
.........................( .......... . . .. and provided by nurses and home health aides. Your
Plan Physician will peri dically review the pr gram
for continuing appropriateness and need.
Services include intravenous therapy and medications.
Nothing Nothing
.............
......... .....( by, or for the convenience of, the p tient or the p tient s family.
Home care primarily for personal assistance that does not include a medical component and is not
diagnostic, therapeutic or rehabilitative
All charges All charges
30.
30
Page 31
32
.
......... .
. ... :$ ......... ..
.
Chiropractic care
High Optio
You pay
Standard Option
You pay
). ....... . services up t 20 visits per member per
calendar year
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electric muscle stimulation, vibrat ry therapy and c ld pack
application
$ 15 per PCP visit
$ 20 per specialist
visit
$ 20 per PCP visit
$ 25 per specialist
visit
..................................... )... All charges All charges
.. .... ...
... ... .
...)....... All charges All charges
Educational classes and programs .
Asthma
Diabetes
Congestive heart failure
Low back pain
C ronary artery disease
Also see the Non-FEHB page f r our InteliHealth and
Fitness Pr gram.
Nothing Nothing
31.
31
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33
......... .
. ... :> .........). .
........ .
.. ........................ services provided by physicians and
other health care professionals .
I
M
P
O
R
T
A
N
T .
Here are some important things to keep in mind about these benefits:
............(........ all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, *.............................. .....
....(... informati n about how cost sharing works. Also read Secti n 9 about
coordinating benefits with other coverage, including with Medicare.
The am unts listed below are f r the charges billed by a physician or ther health care professional for your surgical care. Look in Section 5 ( c) f r
charges associated with the facility ( i. e. , h spital, surgical center, etc. )
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification
informati n shown in Section 3 t be sure which services require
precertification and identify which surgeries require precertification.
*
M
P
O
R
T
A
N
T
Be efit Description
High Optio
You pay
Standard Option
You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures Treatment of fractures, including casting
Normal pre-and post-operative care by the surge n Correction f amblyopia and strabismus
Endoscopy pr cedures Biopsy procedures
Removal of tumors and cysts C rrection of congenital anomalies ( see reconstructive
surgery)
Surgical treatment of m rbid besity a condition in which an individual weighs 100 pounds or 100% over
his or her normal weight according to current
underwriting standards; eligible members must be age
18 or over. This procedure must be approved in
advance by the HMO.
Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage
inf rmation.
Voluntary sterilization ( e. g. Tubal ligation, Vasectomy) Treatment of burns
NOTE: Generally, we pay for internal pr stheses
( devices) according to where the procedure is done. For
example, we pay Hospital benefits for a pacemaker and
Surgery benefits for insertion of the pacemaker.
$ 15 per PCP
office visit, $ 20
per specialist
visit
$ 20 per PCP
office visit, $ 25
per specialist
visit
Surgical procedures .!.................."..# ..
32.
32
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34
.
2003 Aetna Health 29 Section 5( b)
Surgical procedures .........
...
.. ...
You pay .
Standard Option
You pay
. ot covered:
Revers l of voluntary surgically-induced sterilization
Surgery primarily for cosmetic purposes
Radial keratotomy, including related procedures designed to surgically correct refr ctive errors
Whole blood and concentrated red blood cells not replaced by the member
All charges All charges
$..... ... ... surgery .
4..... to correct a functional defect
Surgery t correct a condition caused by injury r illness if:
The condition produced a major effect on the member s appearance and
The condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or fr m birth and is a significant deviation from the common
form or n rm. Examples of congenital anomalies
are: pr truding ear def rmities; cleft lip; cleft palate;
birth marks; webbed fingers; and webbed t es.
All stages of breast reconstruction surgery f llowing a mastectomy, such as:
Surgery to produce a symmetrical appearance on the other breast;
Treatment of any physical complications, such as lymphedemas;
Breast prostheses and surgical bras and replacements ( see Prosthetic devices)
.&' ..... ................... #. ..... ...........
have the procedure performed on an inpatient basis and
remain in the hospital up t 48 hours after the
procedure.
$ 20 per specialist
visit
$ 25 per specialist
visit
............
Cosmetic surgery any surgical procedure ( ( or any portion of a procedure) performed primarily to
improve physical appearance through change in
bodily form, except repair of ccidental injury
Surgeries related to sex transformation .
All charges All charges
33.
33
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35
.
......... .
. ... @2 .........). .
.
Oral and maxillofacial surgery
High Optio
You pay .
. ......
.. ...
You pay
%... surgical procedures, such as:
Treatment of fractures of the jaws or facial bones;
Surgical correcti n of congenital defects, such as cleft lip and cleft palate;
Medically necessary surgical treatment of TMJ;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Removal of bony impacted wisdom teeth;
Excision of tumors and cysts
Other surgical pr cedures that do n t involve the teeth or their supporting structures.
$ 20 per specialist
visit
$ 25 per specialist
visit
............
Dental implants
Dental care involved with the treatment of temporomandibul r joint dysfunction .
All charges All charges
Organ/ tissue transplants .
0 . .......
C rnea
Heart
Heart/ lung
Kidney
Liver
Lung: Single Double
Pancreas .
Intestinal transplants ( small intestine) and the small intestine with the liver or small intestine with multiple
organs such as the liver, st mach and pancreas
Skin .
Tissue .
Allogeneic ( donor) bone marr w/ peripheral stem cell transplants .
Autologous bone marrow/ peripheral stem cell . transplants ( autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced
Hodgkin s lymph ma; advanced non-Hodgkin s
lymphoma; advanced neuroblast ma; breast cancer;
multiple myeloma; epithelial varian cancer; and
testicular, mediastinal, retroperitoneal and ovarian
germ cell tum rs
$ 20 per specialist
office visit and
nothing for the
surgery
$ 25 per specialist
office visit and
nothing for the
surgery
Organ/ tissue transplants !.................."..# ..
34.
34
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36
.
2003 Aetna Health 31 Section 5( b)
Organ/ tissue transplants .........
...
.. ...
You pay .
Standard Option
You pay
Autologous tandem transplants for testicular tumors .
6.. .....!..................*6!.8. Transplants which are non-experimental r non-investigational are
a covered benefit. C vered transplants must be ordered
by your primary care d ctor and plan specialist
physician and approved by our medical direct r in
advance of the surgery. The transplant must be
perf rmed at hospitals ( Institutes of Excellence)
specifically approved and designated by us to perform
these procedures. A transplant is non-experimental and
non-investigational when we have determined, in our
sole discretion, that the medical community has
generally accepted the procedure as appropriate
treatment for your specific condition. Coverage for a
transplant where you are the recipient includes
coverage for the medical and surgical expenses of a
live donor, to the extent these services are not covered
by another plan or program. .
Limited Be efits Treatment f r breast cancer, multiple
myeloma and epithelial ovarian cancer may be provided in
a National Cancer Institute ( NCI) -or National Institute of
Health ( NIH) -approved clinical trial at a Plan-designated
center of excellence and if approved by the Plan s medical
director in accordance with the Plan s protocols.
NOTE : Harvesting of tissue for storage purp ses only is
not eligible for coverage. If b th the donor and the
transplant recipient are covered by us, donor expenses are
attributed to the transplant recipient s coverage. Aetna
does not extend coverage for donor services when the
transplant recipient is not our member.
$ 20 per specialist
office visit and
nothing for the
surgery
$ 25 per specialist
office visit and
nothing for the
surgery
............
Transplants not listed as covered
All charges All charges
.... .... .
....... ........
.......
.... .
Hospital ( inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
.&' ..."................ .... ... ........ ... ..
......
services, such as for pain management, the specialist copay
applies.
Nothing Nothing
35.
35
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37
......... .
. ... @: ............
........ .
.. ........................ or other facility,
and ambulance services .
I
M
P
O
R
T
A
N
T .
Here are some important things to remember about these benefits:
............(............(.... .........(=.............. . . ... limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary.
Plan physicians must provide or arrange your care and you must be h spitalized in a Plan facility.
Be sure to read Section 4, *.............................. .....
....(... informati n about how cost sharing works. Also read Secti n 9 about
coordinating benefits with other coverage, including with Medicare.
The am unts listed below are f r the charges billed by the facility ( i. e. , hospital or surgical center) or ambulance service for your surgery or care.
Any costs ass ciated with the professional charge ( i. e. , physicians, etc. ) are
covered in Sections 5( a) or ( b) .
%.+....%.* *. ..+.&..'&...' '.&*,* .&*. ..,. HOSPITAL STAYS. .................4... ...@....(......... ......
....
require precertification
*.
..
..
..
..
&.
..
.
&
Be efit Description
High Optio
You pay .
. ......
.. ...
You pay
Inpatie t hospital .
A........(.... such as
Ward, semiprivate, or intensive care accommodations;
General nursing care; and
Meals and special diets.
NOTE : If you want a private room when it is not
medically necessary you pay the additional charge
above the semiprivate ro m rate.
$ 150 per day up to
a maximum of
$ 450 per admission
$ 250 per day up to
a maximum of
$ 750 per admission
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood products, derivatives and components, artificial blood products and biological serum.
Blood products include any product created from a
component of blood such as, but not limited t ,
plasma, packed red blood cells, platelets, albumin,
Factor VIII, Immunogl bulin, and prolastin
Dressings, splints, casts, and sterile tray services
Nothing Nothing
Inpatient hospital !.................."..# .. .
36.
36
Page 37
38
.
2003 Aetna Health 33 Section 5( c)
Inpatie t hospital .........
...
.. ...
You pay .
Standard Option
You pay
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a h spital f r use at
home
Nothing Nothing
.............
Whole blood and concentrated red blood cells not replaced by the member
Custodi l care, rest cures, domiciliary or convalescent cares
Personal comfort items, such as telephone and television
All charges All charges
.. .. ...
.... .. or ambulatory surgical
center
%..... ..#.....
.. #..........................
Prescribed drugs and medicines
Radiologic procedures, diagnostic laboratory tests, and X-rays when ass ciated with a medical
procedure being done the same day
Pathology Services
Administration f blo d, blood plasma, and other biologicals
Blood products, derivatives and components, artificial blood products and biological serum
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
.&' .."....
....... ... services and supplies related
t dental procedures when necessitated by a non-dental
physical impairment. We d not cover the dental
procedures.
$ 125 per visit $ 200 per visit
Outpatient hospital or ambulatory surgical center !.................."..# ...
37.
37
Page 38
39
.
2003 Aetna Health 34 Section 5( c)
.. .. ... hospital or ambulatory surgical
center .........
High Optio
You pay
Standard Option
You pay
4..
............. ...... ........ ..............(. ...
done the same day, such as:
Mammogram
Radiologic procedure
Lab tests .&'
. There is no copay for a routine mammogram.
If, however, it is perf rmed in conjuncti n with an
office visit, the PCP or specialist copay would apply.
$ 20 per
specialist visit
$ 25 per
specialist visit
............. Whole blood and concentrated red blood
cells not replaced by the member
All charges All charges
.% .....
....
...... .&.'.....
.......
....
facility benefits
.
Extended care benefit: All necessary services during
confinement in a skilled nursing facility with a 90-day
limit per calendar year when full-time nursing care is
necessary and the confinement is medically appropriate as
determined by a Plan doct r and approved by the Plan.
Nothing Nothing
.............! ustodial care All charges All charges
.......
....
4......
.......... ..
........ r a terminally ill member
in the h me r h spice facility, including inpatient and
outpatient care and family counseling, when provided
under the directi n of a Plan d ctor, wh certifies the
patient is in the terminal stages of illness, with a life
expectancy f approximately 6 months r less.
Nothing Nothing
Ambulance
Ambulance service ordered or authorized by a Plan doct r Nothing Nothing
..............+).. ... services for routine
transport tion to receive outp tient or inpatient
services.
All charges All charges
38.
38
Page 39
40
.
2003 Aetna Health 35 Section 5( d)
........ .
.. .......... services/ accidents
.
I
M
P
O
R
T
A
N
T .
Here are some important things to keep in mind about these benefits:
............( that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary.
Be sure to read Section 4, *...................... .... valuable informati n about how cost sharing works. Also read Secti n 9 about
coordinating benefits with other coverage, including with Medicare. .
I
M
P
O
R
T
A
N
T .
What is a medical emergency?
..... ............ is the sudden and unexpected onset of a condition or an injury that you believe
endangers y ur life or could result in serious injury r disability, and requires immediate medical or surgical
care. Some problems are emergencies because, if n t treated promptly, they might become more serious;
examples include deep cuts and broken bones. Others are emergencies because they are p tentially life-
threatening, such as heart attacks, str kes, p isonings, gunsh t wounds, or sudden inability to breathe. There
are many other acute conditions that we may determine are medical emergencies what they all have in
common is the need for quick action.
( .
.
..
..
....
..
.........
... .. need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An
emergency medical condition is one manifesting itself by acute sympt ms of sufficient severity such that a
prudent laypers n, who possesses average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in serious jeopardy to the person s health, or with respect to a
pregnant woman, the health f the woman and her unborn child.
Whether you are in or out of an Aetna Health HMO service area, we simply ask that you f ll w the guidelines
below when you believe you need emergency care.
Call the local emergency h tline ( e. g. , 911) or go to the nearest emergency facility. If a delay would n t be detrimental t your health, call your primary care provider. Notify your primary care provider as soon as
possible after receiving treatment.
After assessing and stabilizing your condition, the emergency facility should contact your primary care physician s they can assist the treating physician by supplying inf rmation about your medical hist ry.
If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify your primary care physician or us as soon as possible.
( .
.
#.
.. ....
)...
.. .. Health Inc. HMO Service Area
&..(... who are traveling outside their HMO service area or students who are away at school are covered
for emergency and urgently needed care. Urgent care may be obtained from a private practice physician, a
walk-in clinic, an urgent care center or an emergency facility. Certain conditions, such as severe vomiting,
earaches, sore thr ats or fever, are considered urgent care outside your Aetna Health HMO service area and
are covered in any of the above settings.
If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or
emergency problem d es not qualify f r coverage, it may be necessary to provide us with additional
inf rmation. We will send y u an Emergency Room Notification Rep rt to complete, or a Member Services
representative can take this information by telephone.
39.
39
Page 40
41
......... .
. ... @ ............
Follow-up Care after Emergencies w-up care should be coordinated by your PCP. Foll w-up care with nonparticipating providers is only covered
with a referral from your primary care physician and pre-approval from Aetna Health. Whether you were treated inside
or outside your Aetna Health service area, you must obtain a referral before any f ll w-up care can be covered. Suture
removal, cast removal, X-rays and clinic and emergency room revisits are some examples f foll w-up care.
( .
.
..
..
....
..
......... .
Emergencies withi our service area: If you are in an emergency situation, . you primary care doct r. In extreme emergencies or if you are unable t contact your doctor, contact the local emergency system ( e. g. , the 911
telephone system) or go to the nearest hospital emergency r om. Be sure to tell the emergency room personnel that you
are a Plan member s they can notify your primary care doct r. You or a family member must notify your primary care
doctor as soon as possible after receiving emergency care. It is your responsibility to ensure that your primary care
doct r has been timely notified.
If you need to be hospitalized, the Plan must be notified as soon as possible. If you are hospitalized in non-Plan
facilities and a Plan d ctor believes care can be better pr vided in a Plan hospital, y u will be transferred when
medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any foll w-up care recommended by non-participating providers must be approved by us or
provided by plan providers.
Emergencies outside our service area: . are available for any medically necessary health service that is immediately required because of injury r unf reseen illness.
If you need to be hospitalized, the Plan must be notified as soon as possible. If a Plan doct r believes care can be better
pr vided in a Plan h spital, you will be transferred when medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any foll w-up care recommended by non-participating providers must be approved by us or
provided by plan providers.
Be efit Description
High Optio
You pay
Standard Option
You pay
Emergency withi our service area
Emergency care at a doct r s office $ 15 per PCP visit $ 20 per specialist
visit
$ 20 per PCP visit
$ 25 per specialist
visit
Emergency care as an outpatient in a hospital r an urgent care center
NOTE : If the emergency results in admission t a
hospital the copay is waived.
$ 100 per visit $ 100 per visit
.............&......... ......... emergency c re All charges All charges
......... outside our service area
........ care at a doct r s office $ 20 per specialist visit $ 25 per specialist visit
Emergency care as an outpatient in a hospital r an urgent care center
.&' .. If the emergency results in admission t a
hospital the copay is waived.
$ 100 per visit $ 100 per visit
Emergency outside our service area !.................."..# ...
40.
40
Page 41
42
.
2003 Aetna Health 37 Section 5( d)
......... outside our service area
.........
High Optio
You pay .
. ......
.. ...
You pay
.............
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could h ve been foreseen before
leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area
All charges All charges
.........
....... .......(...... service when medically
appropriate. Air ambulance may be covered. Prior
approval is required.
See 5( c) for non-emergency service.
Nothing Nothing
.............. ir ambulance without prior approval All charges All charges
41.
41
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43
2003 Aetna Health 38 Section 5( e)
........ .
.. .................................. benefits
Network Benefit
I
M
P
O
R
T
A
N
T .
Parity
When you get our approval for services and f ll w a treatment plan we approve,
cost-sharing and limitations for Plan mental health and substance abuse benefits
will be n greater than f r similar benefits f r ther illnesses and conditions. .
.........
......!............
....-..!..................
......"..
(
....(.... .........(=.............. . . .. limitations, and exclusions in this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, *.............................. .....
....(... informati n about how cost sharing works. Also read Secti n 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. . below.
I
M
P
O
R
T
A
N
T
Descriptio
High Optio
You pay
Standard Option
You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a
Plan provider and contained in a treatment plan that we
approve. The treatment plan may include services, drugs,
and supplies described elsewhere in this brochure.
NOTE : Plan benefits are payable only when we
determine the care is clinically appropriate t treat your
condition and only when you receive the care as part of
a treatment plan that we appr ve.
Your cost sharing
responsibilities
are no greater than
f r ther illnesses
or conditions.
Your cost sharing
responsibilities
are no greater than
f r ther illnesses
or conditions.
Professional services, including individual or group therapy by providers such as psychiatrists,
psychologists, or clinical social workers
Medication management
$ 20 per visit $ 25 per visit
Diagnostic tests $ 20 per visit $ 25 per visit
Services pr vided by a h spital or other facility
Services in approved alternative care settings such as partial h spitalization, full-day h spitalization,
facility based intensive outpatient treatment
$ 20 per outpatient
visit
$ 25 per outpatient
visit
Inpatient service:
Appr ved residential treatment facility
Hospital service
$ 150 per day up to a
maximum of $ 450
per admission
$ 250 per day up to a
maximum of $ 750
per admission
Mental health and substance abuse benefits !.................."..# ..
42.
42
Page 43
44
.
2003 Aetna Health 39 Section 5( e)
*.. ..
...
...
.... ....
..... benefits
.........
...
.. ...
You pay .
Standard Option
You pay
............
Services we have not approved
Out of network ment l health and substance abuse services .
.&' ..,$-......) ....................#..... )....
treatment pl ns on the treatment pl n' s clinical
appropriateness. OPM will gener lly not order us to
pay or provide one clinically appropri te treatment
plan in favor of nother. .
All charges All charges
Preauthorization .............#...... ..(...
....................
....*....#.............. care for mental disease or illness, alcohol abuse and/ or substance abuse)
are managed by an independently contracted organization ( Behavi ral
Health Contractor) . This organization makes initial coverage
determinations and coordinates referrals; any behavioral health care
referrals will generally be made to providers affiliated with the
organizati n, unless your needs for covered services extend beyond the
capability of the affiliated pr viders. Emergency care is covered ( see
Section 5( d) , Emergency services/ accidents) . You can receive
information regarding the appropriate way to access the behavioral health
care services that are covered under your specific plan by calling
Member Services at 1-800/ 537-9384 or, by calling the Behavioral Health
Contractor number on the front of your ID card. A referral from your
PCP is not necessary to access the Behavioral Health Contractor but your
PCP may assist with your referral t the Behavi ral Health Contractor.
+. ...'
.... . ... ".... .. . .. ....(.... ... .. ...........(.. ...................
43.
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......... .
. ... .2 ............
........ .
.. ...........................
.
I
M
P
O
R
T
A
N
T .
Here are some important things to keep in mind about these benefits:
"....
......... (................ ... ...#......... (... ............ beginning on the next page. .
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically
necessary. .
Be sure to read Section 4, *.............................. .....
....(... informati n about how cost sharing works. Also read Secti n 9 about
coordinating benefits with other coverage, including with Medicare. .
Certain drugs require your doctor to get precertification from the Plan before they can be prescribed under the Plan. Upon approval by the Plan, the
prescription is good f r the current calendar year r a specified time period,
whichever is less. .
*
M
P
O
R
T
A
N
T .
.
There are important features you should be aware of. !..... ........
#..................!..
...!....)..... ......... . . .. or dentist must write the prescription.
#........................) 9... fill n n-emergency prescriptions at a participating Plan retail pharmacy or by mail rder for up t a 90-day supply of medication ( if authorized by your physician) . You
may obtain up t a 30-day supply of medication f r one copay, and for a 31-day up t a 90-day supply of
medication f r two copays. In n event will the copay exceed the cost of the prescription drug. Please call
Member Services at 1-800/ 537-9384 f r m re details on how t use the mail order program. In an
emergency or urgent care situation, you may fill y ur covered prescription at any retail pharmacy. If y u
obtain your prescription at a participating retail pharmacy and request direct reimbursement from us, we
will review your claim to determine whether the claim is covered under the terms and conditions of your
benefit plan. If you obtain your prescription at a pharmacy that does not participate with the plan, you will
need to pay the pharmacy the full price of the prescription and submit a claim f r reimbursement subject to
the terms and conditions of the plan. .
We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan s drug formulary. The Plan s formulary does not exclude medications from coverage, but requires a higher
copayment for nonformulary drugs. Certain drugs require your doctor to get precertification from the Plan
before they can be prescribed under the Plan. Visit our website at www. aetna. com/ cust m/ fehbp to review
our Formulary Guide or call 1-800/ 537-9384.
Precertification. Your pharmacy benefits plan includes ur precertification program. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-
auth rized by ur Pharmacy Management Precertification Unit before they will be covered. Only y ur
physician or pharmacist, in the case of an antibi tic or analgesic, can request pri r auth rization for a drug.
The precertificati n program is based upon current medical findings, manufacturer labeling, FDA
guidelines and c st informati n. The drugs requiring precertification are subject to change. Visit our
website for the current Precertification List. .
These are the dispensing limitations. Covered prescripti n . prescribed by a licensed physician or dentist . obtained at a participating . retail pharmacy or by mail order . be dispensed for up t a
90-day supply of medicati n ( if authorized by your physician) . You may obtain up t a 30-day supply of
medication for one copay, and a 31-day up to a 90-day supply of medication f r two copays. In no event
will the copay exceed the cost f the prescription drug. . A generic equivalent will be dispensed if available,
unless your physician specifically requires a brand name.
Why use generic drugs? ./.... contain the same active ingredients in the same amounts as their brand name counterparts and have been approved by the FDA. By using generic drugs, when available, most
members see cost savings, without jeopardizing clinical outc me or c mpr mising quality.
#................"...........) 4.... Health Inc. , Pharmacy Management, Claim Processing, P. O. Box 398106, Minneapolis, MN 55439-8106.
2003 Aetna Health 41 Section 5( f) .
Benefit Description
High and
Standard Option
Y u pay
Covered medicati ns and supplies
We cover the fol owing medications and supplies prescribed by a P an
physician or dentist and obtained from a P an pharmacy or through our
mai order program:
Drugs for which a prescription is required by Federal aw, except those listed as Not covered .
Oral contraceptive drugs
Insulin
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies imited to lancets, alcohol swabs, urine test strips/ tablets, and blood glucose test strips
Contraceptive drugs and devices
Oral fertility drugs
Nutritional formulas for the treatment of phenylketonuria, branched-chain ketonuria, galectosemia and homocystinuria when administered
under the direction of a P an doctor
Intravenous fluids and medications for home use, imp antable drugs, IUDs and some injectable drugs are covered under Medical and
Surgical Benefits. See Section 5( a) for details.
NOTE: ........
......
for in vitro fertilization.
Please refer to Section 5( a) , Medical Services and Supplies, Infertility
Services ..
Retail Pharmacy or Mail Order
Pharmacy, for up to a 30-day
supply per prescription or
refill:
$ 10 per covered generic
formulary drug;
$ 25 per covered brand name
formulary drug; and
$ 40 per covered non-
formulary ( generic or brand
name) drug
Retail Pharmacy or Mail Order
Pharmacy, for a 31-day up to a
90-day supply per prescription
or refill:
$ 20 ( two copays) per covered
generic formulary drug
$ 50 ( two copays) per covered
brand name formulary drug;
and
$ 80 ( two copays) per covered
non-formulary drug ( generic
or brand name)
Limited benefits
....................
......... .......
. ..................
............ limits .
Depo Provera is imited to 5 via s per calendar year
One diaphragm per calendar year
50%
$ 25 copay per vial
$ 25 per diaphragm
Here are some things to keep in mind about our prescription drug program:
A generic equivalent may be dispensed if it is avai able, and where al owed by law.
To request a copy of the Aetna Health Medication Formulary Guide, cal 1-800/ 537-9384. The information in the Medication Formulary
Guide is subject to change. As brand name drugs lose their patents
and new generics become avai able on the market, the brand name drug
may be removed from the formulary. Under your benefit plan, this
will result in a savings to you, as you pay a lower prescription
copayment for generic formulary drugs. P ease visit our website at
www. aetna. com/ custom/ fehbp for
current Medication Formu ary Guide
information.
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47
......... .
. ... .: ........... .
Covered medicatio s and supplies ..........
...
...
Standard Option
You pay
............
Drugs available without a prescription or for which there is a nonprescription equiv lent av ilable, ( i. e. , an over-the-counter ( OTC)
drug)
Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance.
Smoking-cess tion drugs and medication, including, but not limited to, nicotine patches and spr ys
Drugs used for the purpose of weight reduction ( i. e. , appetite suppressants)
Prophyl ctic drugs, including but not limited to, anti-mal rials, for travel
All charges
46.
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.
2003 Aetna Health 43 Section 5( g)
........ .
.. .........
Feature Descriptio
Services for the deaf and
hearing-impaired
1 -800/ 628-3323
Informed Health Li e Provides eligible members with telephone access t registered nurses experienced in providing information on a variety of health topics.
Informed Health Line is available 24 hours a day, 7 days a week. You
may call Inf rmed Health Line at 1-800/ 556-1555, Inf rmed Health Line
nurses cannot diagnose, prescribe medication or give medical advice.
Maternity Management
Program
Aetna s Moms-to-Babies Maternity Management Pr gram provides
services, informati n, and resources to help improve pregnancy outc mes.
Features of the program include a pregnancy risk survey, obstetrical nurse
care coordination, comprehensive educational inf rmati n n prenatal
care, labor and delivery, newb rn and baby care, a smoking-cessation
program, and more. To enr ll in the program, call toll-free
1-800/ CRADLE-1.
National Medical
Excelle ce Program
National Medical Excellence Program helps eligible members access
appropriate, covered treatment for solid rgan and tissue transplants using
ur Institutes of Excellence network. We coordinate specialized treatment
needed by members with certain rare or complicated conditions and assist
members wh are admitted to a h spital f r emergency medical care when
they are traveling temporarily outside of the United States. Services under
this pr gram must be preauthorized.
Reciprocity benefit If you need to visit a participating primary care physician f r a covered service, and you are 50 miles or more away fr m h me you may visit a
primary care physician from ur plan s approved network.
Call 1-800/ 537-9384 for provider information and l cati n.
Select a doctor from 3 primary care d ctors in that area.
The Plan will auth rize you f r ne visit and any tests or X-rays ordered by that primary care physician.
You must coordinate all subsequent visits through your wn participating primary care physician.
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......... .
. ... .. Section 5( h)
Section 5 ( h) . Dental benefits .
*
M
P
O
R
T
A
N
T .
Here are some important things to keep in mind about these benefits:
............(............(.... .........(=.............. . . ... limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
Your selected Plan primary care dentist must provide or arrange covered care.
We cover hospitalization f r dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health of the
patient. See Section 5 ( c) for inpatient hospital benefits. . We do n t cover the dental
procedure unless it is described below.
Be sure to read Section 4, *.............................. n
about how cost sharing w rks. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare
*.
.
P
O
R
T
A
N
T .
.
Accidental injury benefit
...)... other than those listed on the following schedule. .
Dental Benefits
High and Standard Option
You pay
Service .
.....
...
%.. ...
. ............
..... ... limited to 2 visits per year
Bitewing x-rays limited t 2 sets of bitewing x-rays per year
Entire x-ray series limited to 1 entire x--ray series in any 3 year peri d
Periapical x-rays and other dental x-rays as necessary
Diagnostic models
Preventive
Prophylaxis ( cleaning of teeth) limited t 2 treatments per year
Topical flu ride limited t 2 courses of treatment per year and t
children under age 18
Oral hygiene instructi n
Restorative ( Fillings)
........*.. ... 8.1........
Amalgam ( primary) 2 surfaces
Amalgam ( primary) 3 surfaces
Amalgam ( primary) 4 surfaces
Amalgam ( permanent) 1 surface
Amalgam ( permanent) 2 surfaces
Amalgam ( permanent) 3 surfaces
Amalgam ( permanent) 4 surfaces
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
$ 5
Dental Benefits !.................."..# ...
48.
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50
.
2003 Aetna Health 45 Section 5( h)
Dental Benefits .........
.. gh and Standard Option
You pay
Service .
...
.........
..........
,.........=.........*................ ..B..............8
'.........
Pulp cap direct
Pulp cap indirect
$ 5
$ 5
$ 5
NOTE: The above services are only covered when provided by your selected participating primary care
dentist in accordance with the terms of your Plan. /...........).. .# .....# ......#... .... ...... ...#........
at reduced fees. Pediatric dentists are considered specialists. .).... ...........
..... ...(.....
....( . ....
selected participating primary care dentist at reduced fees. A partial list appears below. Ask your selected
participating primary care dentist for a complete schedule of current reduced member fees. All member fees
must be paid directly to the participating dentist.
Each empl yee and dependent must select a primary care dentist from the directory and include the dentist s
name on the enr llment or pr vider selection form.
The following services are also available from your selected participating primary care dentist up to the
maximum fee shown. 0...... +........... from a specialist may require you to
fee that is higher than the st ted maximum ..).... ................. . ... ..... ... .......... ......
participating dental specialist for the specific fee in your area.
.......
High and Standard Option
You pay up to
a maximum fee of
Diagnostic
4....... per permanent tooth
Space maintainer
Restorative ( Fillings)
Resin ( anteri r) 1 surface
Resin ( anterior) 2 surfaces
Resin ( anterior) 3 surfaces
Resin ( anterior) 4 or more surfaces or incisal angle
Metallic inlay
$ 35
$ 560
$ 110
$ 145
$ 175
$ 190
$ 725
Prosthodontics, removable
C mplete denture, ( upper or l wer)
Immediate denture ( upper or lower)
Partial denture resin base ( upper or l wer)
Partial denture cast metal framework with resin base ( upper or lower)
Denture repairs
Add tooth t existing partial
Add clasp t existing partial
$ 1,025
$ 1,110
$ 790
$ 1,200
$ 150
$ 135
$ 150
Dental benefits .
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51
.
2003 Aetna Health 46 Section 5( h)
#.. ..
,..... .
.........
.
.......
High and Standard Option
You pay up to
a maximum fee of
Prosthodontics, removable ( Continued) .
,.........(...
Denture relines
Interim denture ( complete or partial/ upper or lower)
Tissue conditioning
fixed
.. ........ .
Metallic inlay/ onlay
Cast metal retainer for resin bonded prosthesis
Crown porcelain
Crown cast
Recement bridge
P st and core
.... surgery
.-..... ....*....... ......... ..... ...
Anesthesia ( general in office, first half-hour session)
$ 375
$ 325
$ 465
$ 110
$ 875
$ 815
$ 315
$ 860
$ 865
$ 85
$ 315
$ 475
$ 270
...........
./.............0
/ ..
..... .....'.......
Gingival curettage per quadrant
Periodontal surgery
Pr visional splinting
Scaling and root planing per quadrant
Periodontal maintenance procedure
'.........
./..........0
!........ ..........
Root canals ( anteri r, bicuspid, molar) excluding final rest rati n
Apicoectomy anterior
...........
.
Pre-rthod ntic treatment visit
Fully banded case ( adult age 19 and over)
Fully banded case ( child age 18 and under)
$ 315
$ 150
$ 760
$ 160
$ 150
$ 110
$ 125
$ 760
$ 510
$ 350
$ 5,625
$ 5,625
#............. ...).. .. .................#.......... ....+ ".+. Ask
your primary care dentist for a complete schedule of reduced fees.
Services not received from a p rticipating dental provider re not
covered. We offer no other dental benefits than those shown above.
All charges
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.
2003 Aetna Health 47 Section 5( i)
........ .
.. .... FEHB benefits available to Plan members
!...(.... ..................... ................................................ ..#................".......
FEHB disputed claim about them. ..... ..... ..............
................................... (.......
catastrophic protecti n out-f-pocket maximums.
.. ..
+..... ..
......6.
...... .......7.....(.................... service website that provides a single source f r online
benefits and health-related inf rmation. As an enrolled Aetna plan member, you can register for a secure
personalized view of your Aetna benefits through this site.
Once registered, the self-service features allow y u to: review eligibility, view claim status and Explanation f
Benefits ( EOB) statements, look up and change provider selections, request member ID cards, and receive
personalized health and benefit messages.
Registration assistance is available toll free, Monday through Friday, fr m 7 a. m. t 9 p. m. Eastern Time at
1-800/ 225-3375. Register today at www. aetna. com.
.. ..
.. ... SM
..... ............................
......... ....... ..... ... .. .......
......... -to-use. Harvard
Medical School and the University of Pennsylvania School of Dental Medicine help InteliHealth to provide
trusted and credible health information t its users. InteliHealth features include: a Drug Resource Center,
Disease and Condition Management tools, Health Risk Assessments, the Harvard Sympt m Scout ( an
interactive symptom checker that provides guidance about a variety of symptoms) , Daily Health News
and much m re. Visit InteliHealth at . aetna. com/ cust m/ fehbp. .
".....
... 1
9......... . (..........
....(..... .... ............ ........#...............#.0.. <. the laser vision
corrective procedure, and nonprescription items including sunglasses and eyewear products through the Vision
One Program at more than 4, 000 l cations across the country.
This eyewear discount enriches the routine vision care coverage provided in your health plan, which includes
an eye exam from a participating provider. If your health plan als includes coverage for eyewear such as
prescription eyeglasses or contact lenses, your out-of-pocket expense can be reduced when you use Vision One
discount. You may purchase your eyewear at Vision One locations at discounted rates, and your allowance will
automatically be applied at point of purchase. You don t have to submit the receipt for reimbursement. Your
allowance applies to . #......#...... .............................. .. .
F r more informati n on Vision One eyewear call t ll free 1-800/ 793-8616. F r a referral t a Lasik provider,
call 1-800/ 422-6600.
-. ....
.......
.......................(............... .......... .........
.......
....( ./..(... . TM . Programs ffer
Plan participants:
Low or discounted membership rates at independent health clubs contracted with Gl balFit Discounts on certain home exercise equipment
To determine which program is offered in your area and t view a list of included clubs, visit the GlobalFit
website at www. globalfit. com. If you would like t speak with a GlobalFit representative, you can call the
GlobalFit Health Club Help Line at 1-800/ 298-7800.
1
Vision One is a registered trademark f C le Visi n.
51.
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53
......... .
. .... 48 Section 6
Section 6. General exclusions things we don t cover
!....-.... ... in this section apply t all benefits. ..................
....
!..."...
........
......."..$.............
cover it unless your Pla doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or conditio and we agree, as discussed under Se vices requi ing ou p ior approval ....!....12 .
We do not cover the following:
)....( .... Plan providers except for authorized referrals or emergencies ( see Emergency Benefits) ;
Services, drugs, or supplies y u receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies n t required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigati nal procedures, treatments, drugs or devices;
Procedures, services, drugs, or supplies related t ab rtions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;
Procedures, services, drugs, or supplies related t sex transf rmations;
Services, drugs, or supplies y u receive from a pr vider r facility barred fr m the FEHB Pr gram; r
Services, drugs, or supplies y u receive with ut charge while in active military service.
52.
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54
......... .
. ... .C ..... n 7 .
Section 7. Filing a claim for covered services
".... .............. . . ...#.....
.....
................ ............ . . ..#.....(.. .. .......... .. ........ at Plan
pharmacies, you will n t have to file claims. Just present y ur identification card and pay your copayment or
coinsurance.
You will only need to file a claim when y u receive emergency services from n n-plan pr viders. Sometimes these
pr viders bill us directly. Check with the pr vider. If y u need to file the claim, here is the pr cess:
*......!
.... .. and
drug be efits
. m st cases, pr viders and facilities file claims f r y u. Physicians
must file on the f rm HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 f rm. For claims questions and
assistance, call us at 1-800/ 537-9384.
When you must file a claim such as for services you receive outside of
the Plan s service area submit it on the HCFA--1500 or a claim form
that includes the inf rmation shown below. Bills and receipts should be
itemized and show:
Covered member s name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanati n of benefits, payments, or denial fr m any primary payer such as the Medicare Summary Notice ( ( MSN) ; and
Receipts, if you paid for your services.
Submit your medical, hospital, and dental claims to: Aetna Health,
1425 Union Meeting R ad, P. O. Box 1125, Blue Bell, PA 19422.
Submit your drug claims to: Aetna Health, Pharmacy Management,
Claim Processing, P. O. Box 398106, Minneapolis, MN 55439-8106.
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by
administrative operati ns of Government or legal incapacity, provided
the claim was submitted as soon as reasonably possible.
When we need more i formatio Please reply promptly when we ask for additional inf rmati n. We may delay processing or deny your claim if you do not respond.
53.
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55
......... .
. ... 52 Section 8 .
Section 8. The disputed claims process
......... ............... ................ ............ .......... .. process if you disagree with our decision on
your claim r request for services, drugs, or supplies including a request for preauth rization: :
. .. Description
1 ..<.... .... . ............ ........ . . ...... . ....9........ ( a) Write to us within 6 months fr m the date f our decision; r
( b) Send your request t us at: Aetna Health, 1425 Uni n Meeting R ad, P. O. Box 1125, Blue Bell, PA
19422; and
( c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and
( d) Include copies of documents that support your claim, such as physicians letters, , operative reports, bills,
medical records, and explanation of benefits ( EOB) forms.
2 We have 30 days from the date we receive your request to: ( a) Pay the claim ( or, if applicable, arrange for the health care provider t give you the care) ; or
( b) Write to you and maintain our denial go t step 4; ; or
( c) Ask you or your provider for more inf rmation. If we ask your provider, we will send y u a copy of our
request go t step 3. .
3 9...... .......
.................. ....... ..................
.. ... .. .. 2... ...........'......"... ... then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the
inf rmation was due. We will base our decision on the inf rmation we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM t review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote t us if we did n t answer that request in s me way within 30 days; ; or
120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office f Insurance Programs, Contracts Division 3,
1900 E St. NW, Washington, D. C. 20415-3630.
Send OPM the foll wing information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of d cuments that supp rt your claim, such as physicians letters, operative reports, bills, medical records, and explanation of benefits ( EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time t call.
NOTE : If you want OPM to review more than one claim, you must clearly identify which documents apply
to which claim.
NOTE : You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical pr viders, must include a copy f your specific written consent with the
review request.
NOTE : The above deadlines may be extended if you show that you were unable t meet the deadline
because of reas ns beyond your contr l.
54.
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56
......... .
. ... 51 .......1 .
5 %.&.. .....
... ..... .......... ....'.......... ........... ....... ... ................ ............. decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
.
If you do not agree with OPM s decision, your only recourse is t sue. If you decide to sue, you must file
the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs or supplies or fr m the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.
OPM may discl se the information it collects during the review process t support their disputed claim
decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your
lawsuit, benefits, and payment f benefits. The Federal c urt will base its review on the rec rd that was
before OPM when OPM decided t uphold or overturn our decision. You may recover only the amount of
benefits in dispute.
NOTE: If you have a serious r life threatening condition ( one that may cause permanent l ss of bodily functi ns or
death if not treated as soon as possible) , and
a) We haven t responded yet to your initial request f r care r preauth rization/ prior appr val, then call us at
1-800/ 537-9384 and we will expedite our review; or
b) We denied y ur initial request f r care r preauthorization/ prior appr val, then:
If we expedite our review and maintain our denial, we will inf rm OPM so that they can give y ur claim expedited treatment too, r
You may call OPM s Health Benefits Contracts Division III at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time.
External Review
If this Plan denied y ur claim f r payment or services, you can ask us to rec nsider your claim. If we still deny y ur
claim, you can seek an independent external review, before asking OPM t review it if:
1. The amount of your claim or service is more than $ 500; and
2. The Plan denied your claim because it did not consider the treatment medically necessary or considered it
experimental or investigational.
The independent external review will use a neutral, independent physician with related expertise to conduct the review.
The Plan will cover the professional fee f r the review and you will pay the c st to compile and send y ur submission to
the Plan.
To request an External Review Form call 1-800/ 537-9384 within 60 days after receiving the Plan s written n tification
that it will uphold its original decision to deny your claim.
The external reviewer will make a decision within 30 days after y u send us all the necessary inf rmation with the
External Review Request Form. Your primary care doctor can request an expedited review in cases of clinical
urgency where your health would be seri usly jeopardized if you waited the full 30 days. . In this case, the external
review organization or physician will make a decision within 72 hours.
To request a detailed description of the external review requirements, call the Plan s Member Relations Office at
1-800/ 537-9384.
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......... .
. ... 5: .......2 .
Section 9. Coordinating benefits with other coverage
When you have other
health coverage
9................ .. ..........
.... . family member have coverage under
another group health plan or have aut mobile insurance that pays health
care expenses without regard t fault. This is called double coverage.
When you have double coverage, one plan n rmally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Ass ciation of Insurance
C mmissioners guidelines. .
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance,
up to our regular benefit. We will n t pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
S me pe ple with disabilities, under 65 years of age.
People with End-Stage Renal Disease ( permanent kidney failure requiring dialysis or a transplant) .
Medicare has two parts:
Part A ( Hospital Insurance) . Most people do not have t pay for Part A. If you or your sp use worked for at least 10 years in Medicare-
covered employment, you sh uld be able to qualify for premium-free
Part A insurance. ( S meone who was a Federal empl yee on January
1, 1983 or since automatically qualifies. ) Otherwise, if y u are age
65 or older, you may be able t buy it. Contact 1-800/ MEDICARE
for inf rmati n.
Part B ( Medical Insurance) . Most people pay monthly f r Part B. Generally, Part B premiums are withheld from your monthly S cial
Security check r your retirement check.
If you are eligible for Medicare, you may have ch ices in how you get
your health care. Medicare+ Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
informati n in the next few pages shows how we coordinate benefits
with Medicare, depending on the type of Medicare managed care plan
you have.
&.................... Plan ( Part A or Part B) !...%. . ....&.. .... Plan ( Original Medicare) is available everywhere in the United States. It is the way everyone used t get Medicare benefits
and it is the way most people get their Medicare Part A and Part B
benefits. You may g to any doctor, specialist, or hospital that accepts
Medicare. Medicare pays its share and you pay your share. Some things
are not covered under Original Medicare, like prescription drugs. . .
When you are enr lled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by your Plan PCP or
precertified as required. Also, please note that if your Plan physician
d es n t participate in Medicare, you will have to file a claim with
Medicare.
56.
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58
......... .
. ... 5@ .......2.
Claims process when you have the Original Medicare Plan 9...
pr bably will never have to file a claim f rm when you have b th our
Plan and the Original Medicare Plan
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In m st cases, your claims will be coordinated
automatically and we will then pr vide secondary benefits f r
covered charges. You will n t need to do anything. T find out if you
need to d something to file your claim, call us at 1-800/ 537-9384. .
#.. ... .... ...... .... ..
.
. .". .... ......... ........ Plan is your
primary payer. .
[ Primary payer chart begins on next page. ] .
. .
.
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59
2003 Aetna Health 54 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you or your covered spouse are age 65 or over and
Original Medicare This Plan
1) Are an active employee with the Federal government ( including when you
or a family member are eligible for Medicare solely because of a disability) ,
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
( Ask your employing office which of these applies to you. )
4) Are a Federal judge who retired under title 28, U. S. C. , or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C.
( or if your covered spouse is this type of judge) ,
5) Are enrolled in Part B only, regardless of your employment status,
( for Part B
services)
( for other
services)
6) Are a former Federal employee receiving Workers Compensation and
the Office of Workers Compensation Programs has determined that
you are unable to return to duty,
( except for claims
related to Workers
Compensation. )
B. When you or a covered family member have Medicare based
on end stage renal disease ( ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision,
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
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......... .
. ... 55 Section 9
........ managed care plan ... ......... . (.......&.. .... you may choose t enroll in and get your Medicare benefits fr m a Medicare managed care plan. These are health
care choices ( like HMOs) in some areas of the country. In m st Medicare
managed care plans, you can only go t doct rs, specialists, or hospitals
that are part of the plan. Medicare managed care plans provide all the
benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn m re about enrolling in a Medicare managed
care plan, contact Medicare at 1-800/ MEDICARE ( 1-800/ 633-4227) r
at www. medicare. gov.
If you enr ll in a Medicare managed care plan, the foll wing options are
available to you: .
&..
..................!...4
......... managed care plan: .9..... .
enroll in an ther plan s Medicare managed care plan and also remain
enr lled in ur FEHB plan. We will still pr vide benefits when y ur
Medicare managed care plan is primary, even out of the managed care
Plan s network and/ r service area ( if you use our Plan providers) , but
we will not waive any of our copayments or coinsurance. If you enroll in
a Medicare managed care plan, tell us. We will need to know whether
you are in the Original Medicare Plan or in a Medicare managed care
plan so we can correctly coordinate benefits with Medicare.
..
!......,'.3................................. managed care
pla : .... .............. or former spouse, you can suspend your
FEHB coverage to enr ll in a Medicare managed care plan, eliminating
your FEHB premium. ( OPM d es not contribute t your Medicare
managed care plan premium. ) F r information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may d so only at the next Open
Season unless you involuntarily l se coverage or move out f the
Medicare managed care plan s service area.
If you do not enroll i Medicare Part A or Part B If y u d n t have one or b th Parts of Medicare, you can still be covered under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can t get premium-free Part A, we will n t ask you to
enr ll in it.
TRICARE and CHAMPVA TRICARE is the health care pr gram f r eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. CHAMPVA provides health coverage to disabled Veterans and
their eligible dependents. If TRICARE or CHAMPVA and this Plan
cover you, we pay first. See your TRICARE or CHAMPVA Health
Benefits Advis r if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA:
If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enr ll in one of these programs, eliminating your FEHB
premium. ( OPM does not contribute t any applicable plan premiums. )
F r information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program,
generally you may d so only at the next Open Season unless you
involuntarily lose coverage under the program.
59.
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61
......... .
. ... 5 .......2 .
Workers Compensation "...........
......
........ :
You need because of a workplace-related illness or injury that the Office of Workers C mpensation Programs ( ( OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar pr ceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our pr viders.
*....... ".... ou have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-
sponsored program of medical assistance: If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in one of
these State programs, eliminating your FEHB premium. For informati n
on suspending your FEHB enr llment, contact your retirement office. If
you later want to re-enroll in the FEHB Program, generally you may do
s only at the next Open Season unless you inv luntarily l se coverage
under the State program.
When other Governme t
agencies are respo sible for
your care
"...........
......
............. ...............#.4....#............
Government agency directly r indirectly pays for them. .
( ..
. ...
...
...........
for i juries .
".... .......
...... ............... .......... ........... ... care
f r injuries or illness caused by an ther person, you must reimburse us
for any expenses we paid. However, we will cover the cost f treatment
that exceeds the am unt y u received in the settlement.
If you do not seek damages y u must agree to let us try. This is called
subrogati n. If you need more informati n, contact us for our
subrogati n procedures.
The Member specifically ackn wledges our right f subrogation. When
we pr vide health care benefits f r injuries or illnesses f r which a third
party is or may be responsible, we shall be subrogated to your rights of
recovery against any third party to the extent of the full cost f all
benefits pr vided by us, to the fullest extent permitted by law. We may
proceed against any third party with or without your consent.
You als specifically ackn wledge our right of reimbursement. This right
f reimbursement attaches, to the fullest extent permitted by law, when
we have pr vided health care benefits f r injuries or illness f r which a
third party is or may be resp nsible and you and/ or your representative
has recovered any amounts from the third party or any party making
payments on the third party s behalf. By providing any benefit under this
Plan, we are granted an assignment of the pr ceeds of any settlement,
judgment or other payment received by you to the extent of the full cost
of all benefits provided by us. Our right f reimbursement is cumulative
with and not exclusive of our subrogati n right and we may choose t
exercise either or both rights f recovery.
60.
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62
........ .
. ... 5$ .......2 .
You and your representatives further agree t :
Notify us pr mptly and in writing when n tice is given t any third party of the intention to investigate or pursue a claim to recover
damages or btain compensati n due to injuries or illness sustained
by us that may be the legal responsibility of a third party; and
Cooperate with us and do whatever is necessary to secure our rights of subrogati n and/ or reimbursement under this Plan; and
Give us a first-priority lien n any recovery, settlement or judgment or other source of compensation which may be had from a third party
to the extent of the full cost of all benefits associated with injuries or
illness pr vided by us f r which a third party is or may be
responsible ( regardless of whether specifically set forth in the
recovery, settlement, judgment or compensation agreement) ; and
Pay, as the first priority, fr m any recovery, settlement or judgment or other source of compensation, any and all amounts due us as
reimbursement for the full cost of all benefits ass ciated with injuries
r illness pr vided by us f r which a third party is or may be
responsible ( regardless of whether specifically set forth in the
recovery, settlement, judgment, or compensation agreement) , unless
otherwise agreed t by us in writing; and
Do nothing to prejudice our rights as set forth above. This includes, but is n t limited to, refraining fr m making any settlement or
recovery which specifically attempts t reduce or exclude the full
............(.... ......
....( ....
We may recover the full c st of all benefits provided by us under this
Plan without regard t any claim of fault on the part of you, whether by
comparative negligence or otherwise. No court costs or attorney fees may
be deducted from our recovery without the prior express written consent
of us. In the event you or your representative fails to cooperate with us,
you shall be responsible for all benefits paid by us in addition to costs
and att rney s fees incurred by us in obtaining repayment.
61.
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63
......... .
. ... 5> ....... 10 .
......... .!.......... of terms we use in this brochure
Calendar year D..... .1.........,....(...@1............. ......................#..... calendar year begins on the effective date of their enr llment and ends on
December 31 of the same year.
........... ). ......... ..... . percentage f our all wance that you must pay for your care. See page 15.
........ ...... ..... ..... -................. . ..... ...... .......
.. covered services. See page 15.
....... services )..........
...(.... ......#......... (... .... ..(.........
Custodial care .. .. ..............
.......... ......&.. .... guidelines, including r m and board, that a) d es not require the skills of technical or
professional pers nnel; b) is not furnished by or under the supervision of
such pers nnel or does not therwise meet the requirements of post-
hospital Skilled Nursing Facility care; or c) is a level such that you have
reached the maximum level of physical or mental function and such
person is not likely t make further significant improvement. Custodial
Care includes any type of care where the primary purpose is to attend t
your daily living activities which do not entail or require the continuing
attention of trained medical r paramedical personnel. Examples include
assistance in walking, getting in and out of bed, bathing, dressing,
feeding, using the t ilet, changes of dressings of non infected, post-
perative or chr nic conditions, preparation of special diets, supervision
f medication which can be self-administered by you, the general
maintenance care f col stomy or ileostomy, routine services to maintain
other service which, in our determination, is based on medically accepted
standards, can be safely and adequately self-administered or performed
by the average non-medical person without the direct supervision of
trained medical or paramedical personnel, regardless of who actually
provides the service, residential care and adult day care, protective and
supportive care including educational services, rest cures, or
convalescent care. Custodial care that lasts 90 days or more is s metimes
known as l ng term care.
!................( .................... ...- .........................
................. ..... ....#. ....... . . .. .......( ............ ....
......... ....... . #................ ....... ........... ...... . ....#.
( .....(.. ................#..... ...- ... ..................#............
.................................. .....( ... .... ............
...... ....( .... ......... . . .. while keeping the physiological risk
to the patient at a minimum.
62.
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64
......... .
. ... 5C ....... 10 .
services
4..
............ ...........#.......... ....( ...#..-... ..............#.
device, pr cedure or treatment will be determined t be experimental if:
There is not sufficient outcome data available from controlled clinical trials published in the peer reviewed literature to substantiate
its safety and effectiveness for the disease or injury inv lved; or
Required FDA approval has not been granted for marketing; or
A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or f r research
purposes; r
The written pr t c l or pr t c l( s) used by the treating facility or the protocol r protocol( s) of any other facility studying substantially the
same drug, device, pr cedure r treatment or the written inf rmed
consent used by the treating facility or by another facility studying
the same drug, device, pr cedure or treatment states that it is
experimental or for research purposes; or
It is not of proven benefit for the specific diagn sis or treatment of your particular condition; r
It is not generally recognized by the Medical Community as effective or appropriate for the specific diagnosis or treatment f your
particular condition; or
It is provided or perf rmed in special settings for research purposes.
*......
....... . .....<........... .... ......... or medically necessary services. Services that are appropriate and consistent with the diagnosis in
accordance with accepted medical standards as described in this
document. Medical Necessity, when used in relation t services, shall
have the same meaning as Medically Necessary Services. This definition
applies only t the determination by us of whether health care services
are Covered Benefits under this Plan.
$.........
. .... !................).
.......... .... ............ ......(...... prevailing charge level made f r the service or supply in the geographic
area where it is furnished. We may take into account factors such as the
complexity, degree f skill needed, type or specialty f the pr vider,
range of services pr vided by a facility, and the prevailing charge in
other areas in determining the Reasonable Charge for a service or supply
that is unusual or is n t often provided in the area or is provided by only
a small number of providers in the area.
$....... Specific directions or instructions from your PCP, in conformance with our policies and procedures, that direct you to a participating provider for
medically necessary care.
Respite care Care furnished during a period of time when your family or usual caretaker cannot, or will n t, attend to your needs.
63.
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65
2003 Aetna Health 60 Section 10 .
Urgent care Covered benefits required n order to prevent serious deteriorat on of your health that results from an unforeseen illness or injury if you are
temporarily absent from our service area and receipt of the health care
service cannot be delayed unt l your return to our service area.
Us/ we Us and we refer to Aetna Health.
You You refers to the enrollee and each covered family member.
64.
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66
......... .
. ... 1 .......33.
.......... .".#$......
No pre-existi g condition
limitation
"... ...................
.......................... . ........ ......
before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get i formation
about e rolling in the FEHB
Program
See www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a .4........%.... ..&+#.......
Health Benefits Plans, .(........................#................ .... ...
need to make an informed decision about . your FEHB coverage. These
materials tell you:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer t an ther Federal agency, go on leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment begins.
We don t determine who is eligible for coverage and, in m st cases,
cannot change your enrollment status without information from your
employing or retirement ffice.
Types of coverage available for
you and your family
Self Only coverage is for you alone. Self and Family coverage is for you,
your spouse, and your unmarried dependent children under age 22,
including any f ster children r stepchildren your empl ying or
retirement office authorizes coverage for. Under certain circumstances,
you may als continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days bef re t 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change t Self and Family because you marry, the change is
effective on the first day of the pay period that begins after your
employing office receives your enrollment form; benefits will n t be
available to your sp use until you marry.
Your empl ying or retirement ffice will not you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from your coverage for any reason, including divorce, r when your child
under age 22 marries or turns 22.
If you or one f your family members is enrolled in one FEHB plan, that
person may not be enr lled in r covered as a family member by another
FEHB plan.
65.
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Page 66
67
......... .
. ... : .......33 .
. ....../.
.... .
.. %.&..... ............................ ................ ... Children s Equity Act of 2000. This law mandates that you be enrolled
for Self and Family coverage in the Federal Employees Health Benefits
( FEHB) Program, if you are an employee subject to a court or
administrative order requiring you t provide health benefits for your
child( ren) .
If this law applies to you, you must enr ll f r Self and Family coverage
in a health plan that provides full benefits in the area where your children
live or provide documentati n t your employing office that you have
obtained other health benefits coverage for your children. If you do n t
do s , your employing office will enroll you involuntarily as follows: .
If y u have n FEHB coverage, y ur employing ffice will enr ll you f r Self and Family coverage in Blue Cross and Blue Shield
Service Benefit Plan s Basic Option;
If you have a Self Only enrollment in a fee-for-service plan r in an HMO that serves the area where your children live, your employing
ffice will change y ur enr llment to Self and Family in the same
option of the same plan; or
If you are enrolled in an HMO that does not serve the area where the children live, y ur employing ffice will change y ur enr llment to
Self and Family in the Blue Cr ss and Blue Shield Service Benefit
Plan s Basic Option.
As long as the court/ administrative order is in effect, and y u have at
least one child identified in the order wh is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or
change to a plan that doesn t serve the area in which your children live,
unless you provide documentation that you have other coverage for the
children. If the c urt/ administrative order is still in effect when y u
retire, and you have at least one child still eligible for FEHB coverage,
you must continue your FEHB coverage into retirement ( if eligible) and
cannot make any changes after retirement. Contact your employing
office for further informati n.
When benefits and
premiums start
The benefits in this brochure are effective on January 1. If you joined this
Plan during Open Season, your coverage begins on the first day of your
first pay peri d that starts on r after January 1. Annuitants coverage
and premiums begin on January 1. If you j ined at any other time during
the year, your empl ying office will tell you the effective date of
coverage.
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years
of your Federal service. If you do n t meet this requirement, you may be
eligible for other forms of coverage, such as Temporary C ntinuation of
Coverage ( TCC) .
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2003 Aetna Health 63 Section 11 .
When you lose benefits
When FEHB coverage ends . will recei e an additional 31 days of co erage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity co erage or Temporary
Continuation of Coverage.
Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not . continue to get benefits under your former spouse s enrollment. This is
the case even when the court has ordered your former spouse to supply
health coverage to you. But, you may be eligible for your own FEHB
coverage under the spouse equity law or Temporary Continuation of
Coverage ( TCC) . If you are recently di orced or are anticipating a
divorce, contact your ex-spouse s employing or retirement office to get
RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees .....
other information about your coverage choices. You can also download
the guide from OPM s website, www. opm. gov/ insure.
Temporary cont nuat on of coverage ( TCC) .......
..
.
.
.. ..
....
............ ..
....
...
..
....
........ longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage ( TCC) . For example, you can recei e TCC if
you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to
gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the ......... ...
... .................................
.
Temporary Continuation of Coverage and Former Spouse Enrollees ..
..........
.. ..........
...
.
........
..........................
..
It explains what you have to do to enroll.
....... .
.... .. . .. .. coverage ............
........... FEHB individual policy if:
Your co erage under TCC or the spouse equity law ends ( If you canceled your coverage or did not pay your premium, you cannot
convert) ;
You decided not to receive co erage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal ser ice, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing co erage, the employing or retirement office will ... notify
you. You must apply in writing to us within 31 days after you are no
longer eligible for coverage.
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Page 68
69
2003 Aetna Health 64 Section 11 .
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we will no impose a waiting period or limit your coverage due to pre-
exis ing condi ions.
Getting a Certificate of
Group Health Plan Coverage
The Health Insurance Portability and Accountability Act of 1996
( HIPAA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose employer
group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group . Heal h Plan Coverage that indicates how long you
have been enrolled with us. You can use this certificate when getting
health insurance or other health care coverage. Your new plan mus
reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as long as
you enroll wi hin 63 days of losing coverage under this Plan. If you have
been enrolled wi h us for less han 12 months, but were previously
enrolled in o her FEHB plans, you may also reques a certificate from
hose plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage ( TCC) under the FEHB Program. See also the
FEHB website ( www. opm. gov/ insure/ health) ; refer to the TCC and
HIPAA frequently asked ques ions. . These highlight HIPAA rules, such
as the requirement that Federal employees mus exhaus any TCC
eligibility as one condition for guaran eed access to individual health
coverage under HIPAA, and have information about Federal and S ate
agencies you can contact for more information.
68.
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70
......... .
. ... 5 6 ong Term Care Insurance .
Long Term Care Insurance Is Still Available!
.
Open Season for Long Term Care I surance
9............... ........... ......... ............. term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If y ou'r a Federal empl yee, you and your spouse need only answer a few questions about your health during
Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.
.
FEHB Doe sn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care," long term care helps y u perf rm the activities of daily living such as bathing r dressing yourself. It can also provide
help you may need due to a severe cognitive impairment such as Alzheimer s disease.
You Can Also Apply Later, But
Empl yees and their sp uses can still apply f r coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have t answer more health-related questions.
F r annuitants and other qualified relatives, the number of health-related questions that y u need t answer is the same during and after the Open Season.
You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won t receive an application automatically. You must request one through the t ll-free number or website listed bel w.
Open Season ends December 31, 2002 act NOW so you won t miss the abbreviated underwriting available t employees and their spouses, and the July 1 age freeze!
Find Out More Contact LTC Partners by calling 1-800/ LTC-FEDS ( 1-800/ 582-3337) ( TDD for the heari g
impaired: 1-800/ 843-3557) r visiting www. ltcfeds. com
to get more informati n and t request an applicati n.
69.
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71
2003 Aetna Health 66 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
A ccidental injury, 29, 44
Allogenic bone marrrow
transplants, 30
Alternative treatment, 27
Ambulance, 2, 13, 14, 16, 32, 34,
36, 37
Anesthesia, 2, 16, 28, 31, 33, 45
Autologous bone marrow
transplants, 22, 30
B lood and blood plasma, 32, 33
C ast( s) , 28, 32, 33, 36
Catastrophic protection, 2, 15, 68
Changes for 2003, 10
Chemotherapy, 22, 25
Chiropractic, 27
Cholesterol, 18
Claims, 2, 8, 11, 16, 49, 53, 54
Coinsurance, 2, 6, 11, 15, 49, 55,
58
Colorectal Cancer Screening, 18
Congenital anomalies, 10, 23, 28,
29, 30
Contraceptive devices and drugs,
20, 41
Covered charges, 53
Crutches, 26
D eductible, 2, 6, 15, 49
Definitions, 3, 17, 32, 35, 38, 40,
44, 58, 67
Dental Care, 15, 16, 30, 33, 44,
45, 46, 67
Disputed claims review, 2, 50, 51
Dressings, 32, 33, 42, 58, 60
Durable medical equipment, 14,
16, 26
E ducational classes and
programs, 16, 27
Emergency, 2, 6, 9, 10, 16, 35,
36, 37, 39, 40, 42, 43, 48, 49,
67
Experimental or investigational,
7, 31, 48, 51, 59
Eyeglasses, 24, 47, 67
F amily planning, 16, 20
Fecal occult blood test, 18
G eneral exclusions, 3, 16, 19, 24,
48
H earing services, 2, 16
Home health services, 14, 16, 17,
26, 33, 34
Hospice care, 3, 7, 10, 17, 28, 32,
35, 38, 40, 44, 49, 52, 53, 54,
55, 58, 65
Hospital, 2, 6, 7, 10, 11, 13, 16,
17, 19, 23, 28, 29, 31, 32, 33,
36, 37, 38, 43, 49, 52, 55, 56,
67
I mmunizations, 6, 18, 19
Infertility, 20, 21
Insulin, 26, 41
M ail order prescription drugs, 41
Mammograms, 17
Medicaid, 3, 56, 57, 65
Medically necessary, 7, 13, 17,
19, 21, 22, 24, 28, 30, 32, 35,
36, 38, 40, 44, 48, 51, 59
Medicare, 3, 7, 10, 17, 28, 32, 35,
38, 40, 44, 49, 52, 53, 54, 55,
57, 58, 60, 65, 66
Members, 3, 7, 8, 11, 16, 28, 40,
43, 61
N urse, 22, 26, 33, 43
O ccupational therapy, 23
Office visits, 6
Oral and maxillofacial surgery,
10
Orthopedic devices, 25
Oxygen, 26, 33
P ap test, 17, 18
Physical therapy, 11, 23
Physician, 2, 6, 7, 11, 12, 13, 16,
17, 19, 26, 28, 32, 35, 36, 40,
41, 43, 49, 50, 51, 52, 58, 67
Precertification, 7, 13, 28, 32, 40
Prescription drugs, 41, 42, 43
Preventive care, adult, 18
Preventive care, children, 16, 19,
24
Prior approval, 51
Prosthetic devices, 16, 25, 26, 28
R adiation therapy, 22, 25
Room and board, 32, 58
S econd surgical opinion, 12
Skilled nursing facility care, 58
Speech therapy, 16
Splints, 32
Subrogation, 56
Substance abuse, 2, 7, 10, 11, 13,
16, 38, 39, 67
Surgery, 13, 16, 28, 29, 31, 46
Oral, 30, 45
Outpatient, 33
Reconstructive 29
Syringes, 41
T emporary continuation of
coverage, 3, 62, 63, 64
Transplants, 16, 30, 31, 43
Treatment therapies, 16, 22
V ision services, 16, 24
W heelchairs, 26
X -rays, 16, 17, 32, 33, 44
70.
70
Page 71
72
......... .
. ... $ .++ ......5.......
for Aet a Health 2003
Do not rely on this chart alo e. .....(... fits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we
cover; for more detail, look inside.
If you want to enroll r change your enrollment in this Plan, be sure t put the correct enr llment code fr m the cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in emergencies.
.
Be efits
High Option
You Pay
Standard Option
You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in
the office. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Office visit copay:
$ 15 primary care;
$ 20 specialist
Office visit copay:
$ 20 primary care;
$ 25 specialist 17
Services provided by a hospital:
Inpatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 150 per day up to a
maximum of $ 450 per
admission
$ 125 per visit
$ 250 per day up to a
maximum of $ 750 per
admission
$ 200 per visit
32
33
Emergency benefits:
In-area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 100 per visit
$ 100 per visit
$ 100 per visit
$ 100 per visit
36
36
Mental health and substance abuse treatment . . . . . . . . Regular cost sharing Regular cost sharing 38
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
You may fill n n-emergency prescriptions at a
participating Plan retail pharmacy or by mail order
for up to a 90-day supply of medication ( if
authorized by your physician) . You may obtain up
t a 30-day supply of medication for one copay, and
a 31-day up to a 90-day supply of medication f r
two copays. In n event will the copay exceed the
cost of the prescription drug.
F r up t a 30-day
supply:
$ 10 per generic
formulary; $ 25 per
brand name formulary;
and $ 40 per
nonformulary ( generic
or brand name) .
F r a 31-day up t a
90-day supply:
Two copays .
F r up t a 30-day
supply:
$ 10 per generic
formulary; $ 25 per
brand name formulary;
and $ 40 per
nonformulary ( generic
or brand name) .
F r a 31-day up t a
90-day supply:
Two copays .
41
Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Variable copays Variable copays 44
Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 copay per visit. Up
to $ 100 reimbursement
f r eyeglasses r
contacts per 24 month
period
$ 25 copay per visit. Up
to $ 100 reimbursement
f r eyeglasses r
contacts per 24 month
period
24
Special Features: Services for the deaf and hearing-
impaired; Inf rmed Health Line; Maternity
Management Program, Nati nal Medical Excellence
Program, and Reciprocity benefits. . . . . . . . . . . . . . . . . . . . . . . . .
Contact Plan Contact Plan 43
71.
71
Page 72
73
......... .
. ... > .++ ......5.......
.
Be efits
High Option
You Pay
Standard Option
You Pay Page
....... ...... .............. . costs
( your catastrophic protecti n out-of-pocket
maximum) ................................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nothing after
$ 1,500/ Self Only or
$ 3,000/ Family
enrollment per year.
S me costs do not
count toward this
protecti n.
Nothing after
$ 1,500/ Self Only or
$ 3,000/ Family
enrollment per year.
S me costs do not
count toward this
protection.
Notes
75.
75
Page 76
2003 Aetna Health Rates
' 3 Rate Information for Aetna Health
( formerly Aetna U. S. Healthcare)
Non-Postal rates . .... ............ Postal enrollees. If you are in a special enrollment category, refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment.
..
........
..... ..................4..
........ .....&......... ............................./. .......;. ....
States Postal Service Employees, RI 70-2. Different postal rates apply and a special FEHB guide .
. published for P stal
Service Inspectors and Office of Inspector General ( OIG) employees ( see RI 70-2IN) .
Postal rates do not apply to n n-career postal employees, postal retirees, or ass ciate members of any postal employee
organizati n who are not career postal employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollme t Code
Gov t
Share
Your
Share
Gov t
Share
Your
Share
USPS
Share
Your
Share
Washington, DC, North and Central Maryland and Norther Virginia
High Option
Self Only JN1 $ 106. 08 $ 35.36 $ 229. 84 $ 76.61 $ 125. 53 $ 15.91
High Option
Self and Family JN2 $ 238. 91 $ 79.64 $ 517. 64 $ 172. 55 $ 282. 71 $ 35.84 .
Standard Option
Self Only JN4 $ 79.31 $ 26.43 $ 171. 83 $ 57.27 $ 93.84 $ 11.90
Standard Option
Self and Family JN5 $ 185. 60 $ 61.86 $ 402. 12 $ 134. 04 $ 219. 62 $ 27.84
. 76.