2024

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See FEHB Facts for details. This Plan is accredited. See Section 1.

Serving: All of Washington, D.C., All of Maryland, and Northern Virginia Areas.

Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See Section 1 for requirements.

Enrollment codes for this Plan:
JN1 High Option - Self Only
JN3 High Option - Self Plus One
JN2 High Option - Self and Family

JN4 Basic Option - Self Only
JN6 Basic Option - Self Plus One
JN5 Basic Option - Self and Family

QQ4 Aetna Saver - Self Only
QQ6 Aetna Saver - Self Plus One
QQ5 Aetna Saver - Self and Family

Important Notice

Important Notice from Aetna About Our Prescription Drug Coverage and Medicare

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

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

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

Please be advised

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

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213 (TTY: 800-325-0778).

Potential Additional Premium for Medicare’s High Income Members

Income-Related Monthly Adjustment Amount (IRMAA)

The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an amount you may pay in addition to your FEHB premium to enroll in and maintain Medicare prescription drug coverage. This additional premium is assessed only to those with higher incomes and is adjusted based on the income reported on your IRS tax return. You do not make any IRMAA payments to your FEHB plan. Refer to the Part D-IRMAA section of the Medicare website:
www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject to this additional premium.

Visit www.medicare.gov for personalized help. You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

• Call 800-MEDICARE (800-633-4227), (TTY: 877-486-2048)

Table of Contents

(Page numbers solely appear in the printed brochure)

• Introduction
• Plain Language
• Stop Healthcare Fraud!
• Discrimination is Against the Law
• Preventing Medical Mistakes
• FEHB Facts
• • No pre-existing condition limitation
  • Minimum essential coverage (MEC)
  • Minimum value standard (MVS)
  • Where you can get information about enrolling in the FEHB Program
  • Enrollment types available for you and your family
  • Family member coverage
  • Children’s Equity Act
  • When benefits and premiums start
  • When you retire
  • When FEHB coverage ends
  • Upon divorce
  • Temporary Continuation of Coverage (TCC)
  • Converting to individual coverage
  • Health Insurance Marketplace
  • Primary care
  • Specialty care
  • Hospital care
  • If you are hospitalized when your enrollment begins
  • Inpatient hospital admission
  • Other services
  • Non-urgent care claims
  • Urgent care claims
  • Concurrent care claims
  • Emergency inpatient admission
  • Maternity care
  • If your treatment needs to be extended
  • To reconsider a non-urgent care claim
  • To reconsider an urgent care claim
  • To file an appeal with OPM
  • TRICARE and CHAMPVA
  • Workers' Compensation
  • Medicaid
  • The Original Medicare Plan (Part A or Part B)
  • Medicare prescription drug coverage (Part D)

  Introduction

  This brochure describes our Open Access Plan (High, Basic and Saver options) benefits under our Aetna* contract (CS 1766) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at 800-537-9384 or through our website: www.aetnafeds.com. The address for the Aetna administrative office is:

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

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

  If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2024, unless those benefits are also shown in this brochure.

  OPM negotiates benefits and rates for each plan annually. Benefit changes are effective January 1, 2024, and changes are summarized in Section 2. Rates are shown at the end of this brochure.

  *The Aetna companies that offer, underwrite or administer benefits coverage are Aetna Health Inc., Aetna Life Insurance Company, and Aetna Dental Inc.

  Plain Language

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

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

  Stop Healthcare Fraud!

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

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

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

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except to your health care providers, authorized health benefits plan or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOBs) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
    • Call the provider and ask for an explanation. There may be an error.
    • If the provider does not resolve the matter, call us at 800-537-9384 and explain the situation.
    • If we do not resolve the issue:

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

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

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

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

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

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

      Discrimination is Against the Law

      The health benefits described in this brochure are consistent with applicable laws prohibiting discrimination.

      Preventing Medical Mistakes

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

      1. Ask questions if you have doubts or concerns.

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

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

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

      3. Get the results of any test or procedure.

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

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

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

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

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

      Patient Safety Links

      For more information on patient safety, please visit:

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

      Preventable Healthcare Acquired Conditions (“Never Events”)

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

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

      FEHB Facts

      Coverage information

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

      • Minimum value standard (MVS)
      • Where you can get information about enrolling in the FEHB Program

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

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

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

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

      We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, disability leave, pensions, etc. you must also contact your employing or retirement office.

      Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

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

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

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

      Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

      Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

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

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

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

      Natural children, adopted children, and stepchildren

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

      Foster children

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

      Children incapable of self-support

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

      Married children

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

      Children with or eligible for employer-provided health insurance

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

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

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

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

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

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

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

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

      The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be paid according to the 2024 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

      • When you retire

      When you lose benefits

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

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

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

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

      If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

      If you were married to an enrollee and your divorce or annulment if final, you may not remain covered as a family member unde r your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at:
      https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

      If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or i f you are a covered child and you turn 26.

      You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

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

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

      You may convert to a non-FEHB individual policy if:

      • Your coverage under TCC or the spouse equity law ends;
      • You decided not to receive coverage 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 or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

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

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

      Section 1. How This Plan Works

      This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory or visit our website at www.aetnafeds.com. We give you a choice of enrollment in a High, Basic or Saver Option.

      OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Aetna holds the following accreditations: National Committee for Quality Assurance and/or the local plans and vendors that support Aetna hold accreditation from the National Committee for Quality Assurance. To learn more about this plan’s accreditation(s), please visit the following website:

      • National Committee for Quality Assurance ( www.ncqa.org)

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

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

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

      General features of our High and Basic Options

      • You can see participating network specialists without a referral (Open Access).
      • You can choose between our Basic Dental or Dental PPO option. Under Basic Dental, you can access preventive care for a $5 copay and other services at a reduced fee. Under the PPO option, if you see an in-network dentist, you pay nothing for preventive care after a $20 annual deductible per member. You may also utilize non-network dentists for preventive care, but at reduced benefit levels after satisfying the $20 annual deductible per member. You pay all charges for other services when utilizing non-network dentists.
      • You receive a $100 reimbursement every 24 months for glasses or contact lenses.

      General Features of our Aetna Saver Option

      • You can see participating network specialists without a referral. (Open Access)
      • Services covered under this plan are subject to coinsurance which means we pay a percentage and you pay a percentage of our negotiated rates with our network providers to keep costs down.
      • Coverage for preventive services like flu shots and physicals.

      We have Open Access benefits

      Our HMO and Aetna Saver Plans offer Open Access benefits. This means you can receive covered services from a participating network specialist without a required referral from your primary care provider (PCP) or by another participating provider in the network.

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

      How we pay providers

      We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).

      This is a direct contract prepayment Plan, which means that participating providers are neither agents nor employees of the Plan; rather, they are independent doctors and providers who practice in their own offices or facilities. The Plan arranges with licensed providers and hospitals to provide medical services for both the prevention of disease and the treatment of illness and injury for benefits covered under the Plan.

      Specialists, hospitals, primary care providers and other providers in the Aetna network have agreed to be compensated in various ways:

      • Per individual service (fee-for-service at contracted rates),
      • Per hospital day (per diem contracted rates),
      • Under capitation methods (a certain amount per member, per month), and
      • By Integrated Delivery Systems (“IDS”), Independent Practice Associations (“IPAs”), Physician Medical Groups (“PMGs”), Physician Hospital Organizations (“PHOs”), behavioral health organizations and similar provider organizations or groups that are paid by Aetna; the organization or group pays the physician or facility directly. In such arrangements, that group or organization has a financial incentive to control the costs of providing care.

      One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal. You are encouraged to ask your physicians and other providers how they are compensated for their services.

      Your rights and responsibilities

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

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

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

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

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

      Your medical and claims records are confidential

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

      Medical Necessity

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

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

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

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

      Mental Health/Substance Abuse

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

      Ongoing Reviews

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

      Authorization

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

      Patient Management

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

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

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

      • Concurrent Review
      • Discharge Planning
      • Retrospective Record Review

      Member Services

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

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

      Privacy Notice

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

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

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

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

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

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

      We may use or share your protected health information (PHI)

      • With the U.S. Office of Personnel Management (OPM)
      • With your employing agency in connection with payment or health care operations
      • When required by federal law

      We’re also required to share your PHI to OPM for its claims data warehouse. The data is used for its Federal Employees Health Benefits (FEHB) Program.

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

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

      This is explained in our Notice of Privacy Practices. This notice clarifies how we use or disclose your Protected Health Information (PHI):

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

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

      If you want more information about us, call 800-537-9384, or write to Aetna, Federal Plans, PO Box 550, Blue Bell, PA 19422-0550. You may also contact us by fax at 860-975-1669 or visit our website at www.aetnafeds.com.

      Service Area

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

      All of Washington, DC.

      All of Maryland.

      In Virginia, the counties of Arlington, Caroline, Clarke, Fairfax, Fauquier, Greene, King George, Loudoun, Madison, Orange, Prince William, Rappahannock, Spotsylvania, Stafford and Westmoreland; plus the cities of Alexandria, Fairfax, Falls Church, Fredericksburg, Manassas, 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 only for emergency or urgent care benefits. We will not pay for any other health care services out of our service area unless the services have prior plan approval.

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

      Section 2. Changes for 2024

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

      Aetna Saver Option only

      • Enrollment Code QQ. Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See Rate Information)
      • Teladoc Health® Consults – The plan has removed the $49 per consult fee. Members will now pay 30% per consult after deductible. (See Section 5(a))

      Changes to High O ption only

      • Enrollment Code JN. Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See Rate Information)
      • Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) – The Plan will auto-enroll retirees who have Medicare into the PDP EGWP option. The benefits offered will be equal to or better than existing pharmacy coverage. (See Section 5(f) and Section 9 for additional details)

      Changes to Basic Option only

      • Enrollment Code JN. Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See Rate Information)
      • Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) – The Plan will auto-enroll retirees who have Medicare into the PDP EGWP option. The benefits offered will be equal to or better than existing pharmacy coverage. (See Section 5(f) and Section 9 for additional details)

      Changes under High, Basic and Saver Options

      • Services that require plan approval (other services) – The Plan updated its list of services that require plan approval. (See Section 3, You need prior Plan approval for certain services)
      • CVS Health Virtual CareConsults – The Plan will add CVS Virtual care as a telehealth option for members. (See Sections 5(a), 5(d) and 5(e) for cost share information)
      • Infertility – The Plan added coverage for Artificial Insemination (AI) and monitoring of ovulation which includes: Intracervical insemination (ICI), Intrauterine insemination (IUI) and Intravaginal insemination (IVI). The Plan will limit coverage of Artificial Insemination to 3 cycles per calendar year. (See Section 5(a) for additional coverage details)
      • Infertility drugs - The Plan added coverage for infertility medications including IVF related drugs. (See Section 5(f))
      • Gender Affirming Care Services - The Plan will expand coverage to include all medically necessary gender affirming care surgeries, including facial gender affirming surgery and body contouring. (See Section 5(b) for coverage details)

      Section 3. How You Get Care

      Open Access HMO

      This Plan is available to our members in those FEHBP service areas identified in Section 1. You can go directly to any network specialist for covered services without a referral from your primary care provider. Whether your covered services are provided by your selected primary care provider (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection (800-537-9384). If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.

      Identification cards

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

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

      Where you get covered care

      You get covered care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance and you will not have to file claims. If you use our Open Access program you can receive covered services from a participating network specialist without a required referral from your primary care provider or by another participating provider in the network.

      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. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.

      Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

      We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

      This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

      This plan provides Care Coordinators for complex conditions and can be reached at
      www.aetnafeds.com for assistance.

      Plan facilities

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

      Balance Billing Protection

      FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

      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 provider. This decision is important since your primary care provider provides or arranges for most of your health care.

      Your primary car e provider can be a general practitioner, family practitioner, internist or pediatrician. Your primary care provider will provide or coordinate most of your health care.

      If you want to change primary care providers or if your primary care provider leaves the Plan, call us or visit our website. We will help you select a new one .

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

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

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

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

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

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

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

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

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

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

        You need prior Plan approval for certain services

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

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

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

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

        • Inpatient confinements (except hospice) - For example, surgical and nonsurgical stays; stays in a skilled nursing facility or rehabilitation facility; and maternity and newborn stays that exceed the standard length of stay (LOS)
        • Ambulance - Precertification required for transportation by fixed-wing aircraft (plane)
        • Autologous chondrocyte implantation
        • Cataract surgery
        • Certain mental health services, inpatient admissions, Residential treatment center (RTC) admissions, Partial hospitalization programs (PHPs), Transcranial magnetic stimulation (TMS) and Applied Behavior Analysis (ABA);
        • Chiari malformation decompression surgery
        • Cochlear device and/or implantation
        • Coverage at an in-network benefit level for out-of-network provider or facility unless services are emergent. Some plans have limited or no out-of-network benefits
        • Covered transplant surgery
        • Dialysis visits -When request is initiated by a participating provider, and dialysis to be performed at a nonparticipating facility
        • Dorsal column (lumbar) neurostimulators: trial or implantation
        • Endoscopic nasal balloon dilation procedures
        • Electric or motorized wheelchairs and scooters
        • Functional endoscopic sinus surgery
        • Gender affirming surgery
        • Hip surgery to repair impingement syndrome
        • Hyperbaric oxygen therapy
        • In-network infertility services and pre-implantation genetic testing
        • Lower limb prosthetics, such as: Microprocessor controlled lower limb prosthetics
        • Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider
        • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
        • Osseointegrated implant
        • Osteochondral allograft/knee
        • Private Duty Nursing (see Home Health services)
        • Proton beam radiotherapy
        • Reconstructive or other procedures that maybe considered cosmetic, such as:
          • Blepharoplasty/canthoplasty
          • Breast reconstruction/breast enlargement
          • Breast reduction/mammoplasty
          • Excision of excessive skin due to weight loss
          • Gastroplasty/gastric bypass
          • Lipectomy or excess fat removal
          • Surgery for varicose veins, except stab phlebectomy
          • Anal fistula surgery
          • Angle ligament repair
          • Arthrocentesis
          • Breast tissue excision
          • Carpal tunnel surgery
          • Circumcision - older than 28 days of age
          • Colonoscopy
          • Colposcopy
          • Complex wound repair
          • Conization of cervix
          • Cystourethroscopy
          • Dilation and curettage (D&C)
          • Esophagogastroduodenoscopy (EGD)
          • Excision of lesion of tendon sheath or joint capsule
          • Ganglion excision
          • Hemorrhoidectomy
          • Hernia repair
          • Hysteroscopy
          • Implant removal (i.e., screw)
          • Intranasal dermatoplasty
          • Intravitreal injection
          • Iridotomy/iridectomy, laser surgery
          • Knee joint manipulation under general anesthesia
          • Laparoscopic cholecystectomy
          • Laparoscopy, diagnostic
          • Laryngoscopy
          • Lithotripsy
          • Mohs surgery
          • Nasal bone fracture, closed treatment
          • Neuroplasty, ulnar
          • Orchiopexy
          • Penile angulation correction
          • Prostate biopsy
          • Septoplasty
          • Skin tissue transfer or rearrangement
          • Subcutaneous soft tissue excision
          • Tendon sheath incision
          • Tenodesis of long tendon of biceps
          • Tonsillectomy (age 12 or older)
          • Transurethral electrosurgical resection of prostate (TURP)
          • Trigger point injections
          • Turbinate resection
          • Tympanostomy
          • Artificial intervertebral disc surgery (cervical spine)
          • Arthrodesis for spine deformity
          • Cervical laminoplasty
          • Cervical, lumbar and thoracic laminectomy/laminotomy procedures
          • Kyphectomy
          • Laminectomy with rhizotomy
          • Sacroiliac joint fusions
          • Spinal fusion surgery
          • Vertebral corpectomy
          • Vertebroplasty/Kyphoplasty

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

          Members must call 800-537-9384 for authorization.

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

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

          Next, provide the following information:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

          • To reconsider a non-urgent care claim

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

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

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

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

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

          3. Write to you and maintain our denial.

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

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

          • To file an appeal with OPM

          Section 4. Your Cost for Covered Services

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

          Copayments

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

          Example: When you see your primary care provider, you pay a copayment of $15 per office visit, or you pay a copayment of $30 per office visit when you see a participating specialist under High Option and a copayment of $25 per office visit to your primary care provider, or you pay a copayment of $55 per office visit when you see a participating specialist under Basic Option.

          Deductible

          A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

          Example: Under the Aetna Saver Option you will need to meet the deductible of $1,000 for Self Only enrollment or $2,000 for Self Plus One or Self and Family enrollment.

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

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

          Coinsurance

          Coinsurance is the percentage of our allowance that you must pay for your care.

          Example: In our Plan, you pay 30% of our allowance for durable medical equipment.

          Differences between our Plan allowance and the
          bill

          • Network Providers agree to accept our Plan allowance so if you use a network provider, you never have to worry about paying the difference between our Plan allowance and the billed amount for covered services.
          • Non-Network Providers (for Dental PPO Option only): If you use a non-network provider for preventive dental care, you will have to pay 50% of our negotiated rate and the difference between our Plan allowance and the billed amount.
          • You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

          Your catastrophic protection out-of-pocket maximum

          After your (copayments and coinsurance) total $5,000 for Self Only enrollment or $10,000 for Self Plus One enrollment or Self and Family enrollment for the High Option, $6,000 for Self Only enrollment or $12,000 for Self Plus One enrollment or Self and Family enrollment for the Basic Option and $6,500 for Self Only enrollment or $13,000 for Self Plus One enrollment or Self and Family enrollment for the Aetna Saver Option in any calendar year, you do not have to pay any more for covered services. Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical expenses at 100%. The remaining balance of the Self Plus One and Self and Family out-of-pocket maximum can be satisfied by one or more family members. If you are enrolled in our Aetna Medicare Rx – offered by SilverScript. You will have a separate $2,000 out of pocket maximum for your prescription costs. Once you reach this maximum you will no longer pay a cost share for covered drugs. This $2,000 will also apply to the Plan’s out-of-pocket maximum, see above for additional details.
          However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

          • Dental services (Please Note for High and Basic Options: $5 copayments for DMO preventive care and $20 deductible for PPO preventive care count towards your out-of-pocket maximum. All other dental service expenses do not count toward your out-of-pocket maximum).
          • Infertility services covered under the medical benefit.

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

          Carryover

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

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

          Important Notice About Surprise Billing – Know Your Rights

          The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.
          A surprise bill is an unexpected bill you receive for:

          • emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
          • non-emergency services furnished by certain nonparticipating providers with respect to patient visits to participating health care facilities, or for
          • air ambulance services furnished by nonparticipating providers of air ambulance services.

          Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

          Your health plan must comply with the NSA protections that hold you harmless from surprise bills. Any claims subject to the No Surprises Act will be paid in accordance with the requirements of such law. Aetna will determine the rate payable to the out-of-network provider based on the median in-network rate or such other data resources or factors as determined by Aetna. Your cost share paid with respect to the items and services will be based on the qualifying payment amount, as defined under the No Surprises Act, and applied toward your in-network deductible (if you have one) and out-of-pocket maximum.

          Please note: there are certain circumstances under the law where a provider can give you notice that they are out of network and you can consent to receiving a balance bill. For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.aetnafeds.com or contact the health plan at 800-537-9384.

          The Federal Flexible Spending Account Program FSAFEDS

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

          Section 5. High and Basic Option Benefits

          See Section 2 for how our benefits changed this year. See Summary of Benefits for a benefits summary of each option. Make sure that you review the benefits that are available under the option in which you are enrolled.

          (Page numbers solely appear in the printed brochure)

          • Section 5. High and Basic Option Benefits Overview
          • Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals
          • Diagnostic and treatment services
          • Telehealth services
          • Lab, X-ray and other diagnostic tests
          • Preventive care, adult
          • Preventive care, children
          • Maternity care
          • Family planning
          • Infertility services
          • Allergy care
          • Treatment therapies
          • Physical and occupational therapies
          • Pulmonary and cardiac rehabilitation
          • Habilitative therapy
          • Speech therapy
          • Hearing services (testing, treatment, and supplies)
          • Vision services (testing, treatment, and supplies)
          • Foot care
          • Orthopedic and prosthetic devices
          • Durable medical equipment (DME)
          • Home health services
          • Chiropractic
          • Alternative medicine treatments
          • Educational classes and programs
          • Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals
          • Surgical procedures
          • Reconstructive surgery
          • Oral and maxillofacial surgery
          • Organ/tissue transplants
          • Anesthesia
          • Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
          • Inpatient hospital
          • Outpatient hospital or ambulatory surgical center
          • Extended care benefits/Skilled nursing care facility benefits
          • Hospice care
          • Ambulance
          • Section 5(d). Emergency Services/Accidents
          • Emergency within our service area
          • Emergency outside our service area
          • Telehealth Services
          • Ambulance
          • Section 5(e). Mental Health and Substance Use Disorder Benefits
          • Professional services
          • Diagnostics
          • Inpatient hospital or other covered facility
          • Outpatient hospital or other covered facility
          • Not covered
          • Section 5(f). Prescription Drug Benefits
          • Covered medications and supplies
          • Section 5(g). Dental Benefits
          • Accidental injury benefit
          • Service
          • Section 5(h). Wellness and Other Special Features
          • Flexible benefits option
          • Aetna Member Website
          • Services for deaf and hearing-impaired
          • 24-Hour Nurse Line
          • Enhanced Maternity Program:
          • National Medical Excellence Program
          • Reciprocity benefit
          • Summary of Benefits for the High Option of the Aetna Open Access Plan - 2024
          • Summary of Benefits for the Basic Option of the Aetna Open Access Plan - 2024

          Section 5. High and Basic Option Benefits Overview

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

          The High and Basic Option Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also, read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about High and Basic Option benefits, contact us at 800-537-9384 or on our website at www.aetnafeds.com.

          The High and Basic Options offer the same unique features but at different copays:

          • You can see participating network specialists without a referral (Open Access).
          • You have more choices for your dental coverage. You can choose between our Advantage Dental or Dental PPO option. Under Advantage Dental, you can access preventive care for a $5 copay and other services at a reduced fee. Under the PPO option, if you see an in-network dentist, you pay nothing for preventive care after a $20 annual deductible per member. Participating network PPO dentists may offer members other services at discounted fees. Discounts may not apply in all states. You may also utilize non-network dentists for preventive care, but at reduced benefit levels, and after a $20 annual deductible per member. You pay all charges for other services when utilizing non-network dentists.
          • You receive a $100 reimbursement every 24 months for glasses or contact lenses.
          • You can use Aetna Health Connections Disease Management Programs which are available for 34 conditions .

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

          Important things you should keep in mind about these benefits:

          • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
          • Plan physicians must provide or arrange your care.
          • A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
          • Be sure to read Section 4, Yo ur 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.
          • If you live or work in an Aetna Open Access HMO service area, you should select a PCP by calling Member Services at 800-537-9384.
          • If you live or work in an Aetna Open Access HMO service area, you do not have to obtain a referral from your PCP to see a network specialist.
          • The coverage and cost-sharing listed below are for services provided by physicians and other health care professionals for your medical care. See Section 5(c) for cost-sharing associated with the facility (i.e., hospital, surgical center, etc.).

          Professional services of physicians

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

            $15 per primary care provider (PCP) visit

            $30 per specialist visit

            $25 per primary care provider (PCP) visit

            $55 per specialist visit

            $20 per PCP visit

            $30 per specialist visit

            $25 per PCP visit

            $55 per specialist visit

            Please see www.aetnafeds.com/tools.php for information on medical and behavioral telehealth services.

            Members will receive a welcome kit explaining the telehealth benefits.

            Refer to Section 5(e) for behavioral health telehealth consults.

            • Blood tests
            • Urinalysis
            • Non-routine Pap tests
            • Pathology
            • X-rays
            • Non-routine mammograms
            • Ultrasound
            • Electrocardiogram and electroencephalogram (EEG)
            • Sleep Studies

            Nothing if you receive these services during your office visit; otherwise if service performed by another provider,

            $15 per PCP visit

            $30 per specialist

            Nothing if you receive these services during your office visit; otherwise if service performed by another provider,

            $25 per PCP visit

            $55 per specialist

            Diagnostic tests limited to:

            • Bone density tests - diagnostic
            • CT scans/MRIs/PET scans
            • Diagnostic angiography
            • Genetic testing - diagnostic*
            • Nuclear medicine

            Note: The services need precertification. See Section 3 "Services requiring our prior approval".

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

            *Note: Requires precertification. S ee Section 3 "Services re quiring our prior approval".

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

            • Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
              https://www.cdc.gov/vaccines/schedules/
            • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at
              https://shorturl.at/hovHM.
              
            • Individual counseling on prevention and reducing health risks
            • Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at
              https://www.healthcare.gov/preventive-care-women/
            • To build your personalized list of preventive services go to https://health.gov/myhealthfinder
            • Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

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

            Routine mammogram - covered

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

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

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

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

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

            • Well-child care charges for routine examinations, immunizations and care (up to age 22)
              • Seven (7) routine exams to from birth age 12 months
              • Three (3) routine exams from age 12 months to 24 months
              • Three (3) routine exams from age 24 months to 36 months
              • One (1) routine exam per year thereafter to age 22
                
              • Vision screenings through age 17 to determine the need for vision correction*
              • Hearing exams through age 17 to determine the need for hearing correction
              • Routine examinations done on the day of immunizations (up to age 22)

              *For routine eye refraction, see Vision Services

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

              Not covered:

              Complete maternity (obstetrical) care, such as:

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

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

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

              Note: Here are some things to keep in mind:

              • You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
              • You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will extend your inpatient stay if medically necessary, but you, your representative, your participating doctor, or your hospital must precertify the extended stay.
              • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay including the initial examination of a newborn child covered under a Self Only, Self Plus One or Self and Family enrollment. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
              • We pay hospitalization and surgeon services for maternity care (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

              Note: Also see our Enhanced Maternity Program in Section 5 (h).

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

              No copay for routine prenatal care or the first postpartum care visit

              $15 for PCP visit or $30 for specialist visit for postpartum care visits thereafter

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

              No copay for routine prenatal care or the first postpartum care visit

              $25 for PCP visit or $55 for specialist visit for postpartum care visits thereafter

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

              A range of voluntary family planning services limited to:

              • Contraceptive counseling on an annual basis
              • Surgically implanted contraceptives
              • Generic injectable contraceptive drugs, such as Depo-Provera
              • Intrauterine devices (IUDs)
              • Diaphragms
              • Tubal ligation

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

              Voluntary sterilization (See Surgical Procedures Section 5(b))

              Nothing for women

              $15 per PCP visit

              $30 for Specialist visit

              Nothing for women

              $25 per PCP visit

              $55 for Specialist visit

              Infertility is a disease d efined as when a person is unable to conceive or produce conception after one year of egg-sperm contact when the individual attempting conception is under 35 years of age, or after six months of egg-sperm contact when the individual attempting conception is 35 years of age or older. Egg-sperm contact can be achieved by regular sexual intercourse or artificial insemination (intrauterine, intracervical, or intravaginal) as stated in our medical clinical policy bulletin (see Section 10. for definition of Medical Necessity for additional details on Aetna’s Clinical Policy). This definition applies to all individuals regardless of sexual orientation or the presence/availability of a reproductive partner. Infertility may also be established by the demonstration of a disease or condition of the reproductive tract such that egg-sperm contact would be ineffective.

              Diagnosis and treatment of infertility, such as:

              • Testing for diagnosis and surgical treatment of the underlying medical cause of infertility.
              • Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease.* **

              Comprehensive Infertility Services

              • Artificial insemination (AI)* ** and monitoring of ovulation:
                • Intracervical insemination (ICI)
                • Intrauterine insemination (IUI)
                • Intravaginal insemination (IVI)

                Note: We limit Artificial Insemination to 3 cycles per calendar year. The Plan defines a “cycle” as:

                • An attempt at ovulation induction while on injectable medication to stimulate the ovaries with or without artificial insemination
                • An artificial insemination cycle with or without injectable medication to stimulate the ovaries
                • Ovulation induction cycle(s) while on injectable medication to stimulate the ovaries. *
                • Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician *
                • Injectable fertility drugs including but not limited to menotropins, hCG, GnRH agonists, and intravenous immunoglobulins (IVIG). (See Section 5f for coverage)*

                You are eligible for these covered services if:

                • You or your partner have been diagnosed with infertility.
                • You have met the requirement for the number of months trying to conceive through egg and sperm contact.
                • Your unmedicated day 3 Follicle Stimulating Hormone (FSH) level and testing of ovarian responsiveness meet the criteria outlined in Aetna’s infertility clinical policy.

                Note: The Plan does not cover infertility drugs under the medical benefit. See Section 5(f) for coverage.

                Aetna’s National Infertility Unit

                Our NIU is here to help you and is staffed by a dedicated team of registered nurses and infertility coordinators. They can help you with understanding your benefits and the medical precertification process. You can learn more at www.aetnainfertilitycare.com or call the NIU at 1-800-575-5999 (TTY: 711).

                * Subject to medical necessity

                ** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384. Your network provider will request approval from us in advance for your infertility services. If your provider is not a network provider, you are responsible to request approval from us in advance.

                50% of all charges

                Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See Section 4 for details)

                50% of all charges

                Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See Section 4 for details)

                • All infertility services associated with or in support of an Advanced Reproductive Technology (ART) cycle. These include, but are not limited to:
                  • Imaging, laboratory services, and professional services
                  • In vitro fertilization (IVF)
                  • Zygote intrafallopian transfer (ZIFT)
                  • Gamete intrafallopian transfer (GIFT)
                  • Cryopreserved embryo transfers
                  • Gestational carrier cycles
                  • Any related services, products or procedures (such as intracytoplasmic sperm injection (ICSI) or ovum microsurgery).

                  Note: You pay the applicable copay for each visit to a doctor’s office including each visit to a nurse for an injection.

                  $15 per PCP visit

                  $30 per specialist visit

                  $25 per PCP visit

                  $55 per specialist visit

                  Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants in Section 5(b).

                  • Respiratory and inhalation therapy
                  • Dialysis – hemodialysis and peritoneal dialysis

                  Note: Copayment does not apply for peritoneal dialysis when self-administered. Copayment will apply if services are rendered in home by a plan provider.

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

                  Note: Growth hormone therapy is covered under Medical Benefits; office copay applies. We cover growth hormone injectables under the prescription drug benefit.

                  Note: We will only cover GHT when we preauthorize the treatment. Call 800-245-1206 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information and it is authorized by Aetna. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

                  • Applied Behavior Analysis - (see Section 5(e) for benefits)

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

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

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

                  • Qualified Physical therapists
                  • Occupational therapists

                  Note: We only cover therapy when a physician:

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

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

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

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

                  $30 per visit, nothing during a covered inpatient admission

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

                  $55 per visit, nothing during a covered inpatient admission

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

                  $55 per visit, nothing during a covered inpatient admission

                  Note: No day or visit limit applies.

                  $30 per visit, nothing during a covered inpatient admission

                  $55 per visit, nothing during a covered inpatient admission

                  60 visits per person, per calendar year

                  Note: For children up to age 19, no day or visit limit applies for habilitative therapy, see section 5(a) Habilitative therapy

                  $30 per visit, nothing during a covered inpatient admission

                  $55 per visit, nothing during a covered inpatient admission

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

                  $15 per PCP visit

                  $25 per PCP visit

                  $55 per specialist visit

                  All charges over $1,400/ear/every 36-month period

                  Note: member will be reimbursed up to the allowed amount.

                  All charges over $1,400/ear/every 36-month period

                  Note: member will be reimbursed up to the allowed amount.

                  $15 per PCP visit

                  $25 per PCP visit

                  $55 per specialist visit

                  $55 per specialist visit

                  • Fitting of contact lenses
                  • Visiontherapy, including eye patches and eye exercises, e.g., orthoptics, pleoptics, for the treatment of conditions related to learning disabilities or developmental delays
                  • Radial keratotomy and laser eye surgery, including related procedures designed to surgically correct refractive errors

                  $15 per PCP visit

                  $30 per specialist visit

                  $25 per PCP visit

                  $55 per specialist visit

                  Not covered:

                  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
                  • Treatment of weak, strained or flat feet; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open manipulation or fixation)
                  • Foot orthotics
                  • Podiatric shoe inserts
                  • Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes. Limb and torso prosthetics must be preauthorized.
                  • Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.
                  • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
                  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
                  • Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

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

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

                  Note: For information on the professional charges for the surgery to insert an implant or internal prosthetic device, see Section 5(b) Surgical procedures. For information regarding facility fees associated with obtaining orthopedic and prosthetic devices, see Section 5(c).

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

                  Not covered:

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

                  • Oxygen
                  • Dialysis equipment
                  • Hospital beds (Clinitron and electric beds must be preauthorized)
                  • Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
                  • Crutches
                  • Walkers
                  • Insulin pumps and related supplies such as needles and catheters
                  • Medical foods taken for the treatment of Inborn Errors of Metabolism when provided by a participating DME provider and administered under the direction of a physician

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

                  • Elastic stockings and support hose
                  • Bathroom equipment such as bathtub seats, benches, rails and lifts
                  • Home modifications such as stair glides, elevators and wheelchair ramps
                  • Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities
                  • Medical foods that do not require a prescription under Federal law even if your physician or other health care professional prescribes them
                  • Nutritional supplements that are not administered by catheter or nasogastric tubes, except for oral medical foods taken for the treatment of Inborn Errors of Metabolism when administered under the direction of a physician
                  • Home health services ordered by a Plan Physician and provided by nurses and home health aides through a participating home health care agency. Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less. The plan will allow up to 60 visits per member per calendar year. Your Plan Physician will periodically review the program for continuing appropriateness and need.
                  • Services include oxygen therapy.

                  Note: Short-term physical, speech, or occupational therapy accumulate toward the applicable benefit limit (See the physical, speech and occupational therapy benefits in this section).

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

                  • Nursing care for the convenience of the patient or the patient’s family.
                  • Custodial care, i.e. home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative and appropriate for the active treatment of a condition, illness, disease or injury.
                  • Services provided by a family member or resident in the member’s home.
                  • Services rendered at any site other than the member’s home.
                  • Services rendered when the member is not homebound because of illness or injury.
                  • Private duty nursing services.
                  • Transportation.

                  Chiropractic services up to 20 visits per member per calendar year

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

                  $15 per PCP visit

                  $30 per specialist visit

                  $25 per PCP visit

                  $55 per specialist visit

                  Acupuncture - 10 visits per member per calendar year (when considered medically necessary)

                  Note: See Section 5(b) for our coverage of acupuncture when provided as anesthesia for covered surgery.

                  See Section 5 Non-FEHB benefits available to Plan members for discount arrangements.

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

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

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

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

                  Coverage is provided for:

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

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

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

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

                  Nothing for four (4) smokin g cessation c ounseling sessions per quit attempt and two (2) quit attempts per year.

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

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

                  Important things you should keep in mind about these benefits:

                  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                  • Plan physicians must provide or arrange your care.
                  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e., hospital, surgical center, etc.).
                  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

                  A comprehensive range of services, such as:

                  • Operative procedures
                  • Treatment of fractures, including casting
                  • Normal pre- and post-operative care by the surgeon
                  • Correction of amblyopia and strabismus
                  • Endoscopy procedures
                  • Biopsy procedures
                  • Removal of tumors and cysts
                  • Correction of congenital anomalies (See Reconstructive surgery)
                  • Surgical treatment of severe obesity (bariatric surgery) – a condition in which an individual has a body mass index (BMI) exceeding 40 or a BMI greater than 35 in conjunction with documented significant co-morbid conditions (such as coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea, nonalcoholic steatohepatitis (NASH) or refractory hypertension).**
                    • Members must have attempted weight loss in the past without successful long-term weight reduction; and Members must have participated in and been compliant with an intensive multicomponent behavioral intervention through a combination of dietary changes and increased physical activity for 12 or more sessions occurring within 2 years prior to surgery. Blood glucose control must be optimized, and psychological clearance may be necessary.
                    • Open or laparoscopic Roux-en-Y gastric bypass; or
                    • Open or laparoscopic biliopancreatic diversion with or without duodenal switch; or
                    • Sleeve gastrectomy; or
                    • Laparoscopic adjustable silicone gastric banding (Lap-Band) procedures.
                    • Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information

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

                    • Voluntary sterilization for men (e.g., vasectomy)
                    • Treatment of burns
                    • Skin grafting and tissue implants
                    • Gender affirming surgery*
                      The Plan will provide coverage for the following when the member meets Plan criteria:
                      - Surgical removal of breasts**
                      - Breast augmentation (implants/lipofilling)**
                      - Surgical removal of uterus, ovaries and testes**
                      - Reconstruction of external genitalia**
                      - Medically necessary facial gender affirming surgery and body contouring (Note: For more information on coverage details for medically necessary facial and body contouring coverage and criteria, please refer to www.aetnafeds.com/gender-affirming-care )

                    * Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

                    ** Subject to medical necessity based on our clinical policy bulletin.

                    Note: Hormone therapy is covered under Section 5(f), Prescription drug benefits. Prior authorization is required.

                    $15 per PCP visit

                    $30 per specialist visit

                    Nothing for the surgery. See section 5(c) for facility charges.

                    $25 per PCP visit

                    $55 per specialist visit

                    Nothing for the surgery. See section 5(c) for facility charges.

                    • Reversal of voluntary surgically-induced sterilization
                    • Surgery primarily for cosmetic purposes
                    • Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
                    • Routine treatment of conditions of the foot; (see Foot care)
                    • Gender reassignment services that are not considered medically necessary
                    • Surgery to correct a functional defect
                    • Surgery to correct a condition caused by injury or illness if:
                      • the condition produced a major effect on the member’s appearance and
                      • the condition can reasonably be expected to be corrected by such surgery
                      • surgery to produce a symmetrical appearance of breasts
                      • treatment of any physical complications, such as lymphedema
                      • breast prostheses and surgical bras and replacements (See Prosthetic devices)

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

                      $30 per specialist visit

                      Nothing for the surgery. See section 5(c) for facility charges.

                      $55 per specialist visit

                      Nothing for the surgery. See section 5(c) for facility charges.

                      Not covered:

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

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

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

                      $30 per specialist visit

                      Nothing for the surgery. See section 5(c) for facility charges.

                      $55 per specialist visit

                      Nothing for the surgery. See section 5(c) for facility charges.

                      Not covered:

                      These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Section 3, Other services under You need prior Plan approval for certain services.

                      • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
                      • Cornea
                      • Heart
                      • Heart/lung
                      • Intestinal transplants
                        • Isolated small intestine
                        • Small intestine with the liver
                        • Small intestine with multiple organs, such as the liver, stomach, and pancreas

                        $30 per specialist visit

                        Nothing for the surgery. See section 5(c) for facility charges.

                        $55 per specialist visit

                        Nothing for the surgery. See section 5(c) for facility charges.

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

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

                          $30 per specialist visit

                          Nothing for the surgery. See section 5(c) for facility charges.

                          $55 per specialist visit

                          Nothing for the surgery. See section 5(c) for facility charges.

                          Blood or marrow stem cell transplants

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

                          The Plan extends coverage for the diagnoses as indicated below.

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

                            *Approved clinical trial necessary for coverage.

                            $30 per specialist visit

                            Nothing for the surgery. See section 5(c) for facility charges.

                            $55 per specialist visit

                            Nothing for the surgery. See section 5(c) for facility charges.

                            These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence.

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

                            • Allogeneic transplants for:
                              • Advanced Hodgkin's lymphoma
                              • Advanced non-Hodgkin's lymphoma
                              • Beta Thalassemia Major
                              • Chronic inflammatory demyelination polyneuropathy (CIDP)
                              • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
                              • Multiple myeloma
                              • Multiple sclerosis
                              • Sickle Cell anemia
                              • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
                              • Advanced Hodgkin’s lymphoma
                              • Advanced non-Hodgkin’s lymphoma
                              • Breast cancer
                              • Chronic lymphocytic leukemia
                              • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
                              • Chronic myelogenous leukemia
                              • Colon cancer
                              • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
                              • Multiple myeloma
                              • Multiple sclerosis
                              • Myelodysplasia/Myelodysplastic Syndromes
                              • Myeloproliferative disorders (MPDs)
                              • Non-small cell lung cancer
                              • Ovarian cancer
                              • Prostate cancer
                              • Renal cell carcinoma
                              • Sarcomas
                              • Sickle Cell anemia
                              • Advanced childhood kidney cancers
                              • Advanced Ewing sarcoma
                              • Advanced Hodgkin's lymphoma
                              • Advanced non-Hodgkin's lymphoma
                              • Aggressive non-Hodgkin's lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
                              • Breast cancer
                              • Childhood rhabdomyosarcoma
                              • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
                              • Chronic myelogenous leukemia
                              • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
                              • Epithelial ovarian cancer
                              • Mantle Cell (Non-Hodgkin lymphoma)
                              • Multiple sclerosis
                              • Scleroderma
                              • Scleroderma-SSc (severe, progressive)
                              • Small cell lung cancer
                              • Systemic lupus erythematosus
                              • Systemic sclerosis

                              $30 per specialist visit

                              $55 per specialist visit

                              Nothing for the surgery. See section 5(c) for facility charges.

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

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

                              Clinical trials must meet the following criteria:

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

                              B. All of the following criteria must be met:

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

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

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

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

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

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

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

                              4. The member must:

                              a. Not be treated “off protocol,” and

                              b. Must actually be enrolled in the trial.

                              $30 per specialist visit

                              $55 per specialist visit

                              Nothing for the surgery. See section 5(c) for facility charges.

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

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

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

                              Note: For sedation or anesthesia relating to dental services performed in a dental office, see Section 5(g), Dental benefits.

                              Note: When the anesthesiologist is the primary giver of services, such as for pain management, the specialist copay applies.

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

                              Important things you should keep in mind about these benefits:

                              • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                              • Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
                              • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                              • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
                              • Except in emergencies, all hospital admissions and select outpatient surgery require precertification from your participating physician and prior authorization from Aetna. Please refer to Section 3 to be sure which services require precertification.
                              • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.

                              Room and board, such as

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

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

                              Other hospital services and supplies, such as:

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

                              $150 per day up to a maximum of $450 per admission

                              20% of plan allowance per admission

                              • Whole blood and concentrated red blood cells not replaced by the member
                              • Non-covered facilities, such as nursing homes, schools
                              • Custodial care, rest cures, domiciliary or convalescent cares
                              • Personal comfort items, such as phone and television
                              • Private nursing care
                              • Operating, recovery, and other treatment rooms
                              • Prescribed drugs and medications
                              • Radiologic procedures, diagnostic laboratory tests, and X-rays when associated with a medical procedure being done the same day
                              • Pathology Services
                              • Administration of blood, blood plasma, and other biologicals
                              • Blood products, derivatives and components, artificial blood products and biological serum
                              • Pre-surgical testing
                              • Dressings, casts, and sterile tray services
                              • Medical supplies, including oxygen
                              • Anesthetics and anesthesia service
                              • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.

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

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

                              Note: Preventive care services are not subject to copays listed.

                              $150 per visit

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

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

                              *See below for exceptions

                              Note: Preventive care services are not subject to copays listed.

                              $30 per specialist visit

                              $55 per specialist visit

                              Complex diagnostic tests limited to:

                              • Bone density tests - diagnostic
                              • CT scans/MRIs/PET scans
                              • Diagnostic angiography
                              • Genetic testing - diagnostic*
                              • Nuclear medicine

                              Note: These services need precertification. See "Services requiring our prior approval" in Section 3.

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

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

                              Benefit Description : Extended care benefits/Skilled nursing care facility benefits	High Option (You pay)	Basic Option (You pay)
                              Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 60-day limit per calendar year when full-time nursing care is necessary and the confinement is medically appropriate as determined by a Plan doctor and approved by the Plan.	30% of our Plan allowance	30% of our Plan allowance
                              Not covered: Custodial care	All charges	All charges

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

                              1. Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or
                              2. To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or
                              3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
                              4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

                              Ambulance - $100 copay

                              Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day.

                              Ambulance - $100 copay

                              Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day.

                              Not covered:

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

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

                              Section 5(d). Emergency Services/Accidents

                              Important things you should keep in mind about these benefits:

                              • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                              • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                              • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.

                              What is a medical emergency?

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

                              What to do in case of emergency:

                              Emergencies within our Service Area:

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

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

                              • Call the local emergency hotline (e.g., 911) or go to the nearest emergency facility. For non-emergency services, care may be obtained from a retail clinic, a walk-in clinic, an urgent care center or by calling Teladoc. If a delay would not be detrimental to your health, call your primary care 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 provider s o they can assist the treating physician by supplying information about your medical history.
                              • If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Aetna as soon as possible.

                              Emergencies outside our Service Area:

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

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

                              Follow-up Care after Emergencies

                              All follow-up care should be coordinated by your PCP or network specialist. Follow-up care with non-participating providers is only covered with a referral from your primary care provider and pre-approval from Aetna. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care.

                              $15 per PCP visit

                              $30 per specialist visit

                              $25 per PCP visit

                              $55 per specialist visit

                              Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

                              Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

                              $55 per specialist visit

                              Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

                              Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

                              Not covered:

                              • Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
                              • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
                              • Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.

                              • Teladoc Health® consult

                              Please see www.aetnafed.com/tools.php for information on medical and behavioral telehealth services.
                              Members will receive a welcome kit explaining the telehealth benefits.
                              Refer to Section 5(e) for behavioral health telehealth consults.

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

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

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

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

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

                              Air and sea ambulance may be covered. Prior approval is required.

                              Note: See 5(c) for non-emergency service.

                              Ambulance - $100 copayment

                              Air/Sea ambulance - $150 copayment

                              Ambulance - $100 copayment

                              Air/Sea ambulance - $150 copayment

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

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

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

                              Important things you should keep in mind about these benefits:

                              • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                              • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                              • YOU MUST GET PREAUTHORIZATION FOR CERTAIN SERVICES. Benefits are payable only when we determine the care is clinically appropriate to treat your condition. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan. Please see Section 3 of this brochure for a list of services that require preauthorization.
                              • Aetna can assist you in locating participating providers in the Plan, unless your needs for
                                covered services extend beyond the capability of the affiliated providers. Emergency care is
                                covered (See Section 5(d), Emergency services/accidents). You can receive information regarding the appropriate way to access the behavioral health care services that are covered under your specific plan by calling Member Services at 800-537-9384. A referral from your PCP is not necessary to access behavioral health care but your PCP may assist in coordinating your care.
                              • We will provide medical review criteria for denials to enrollees, members or providers upon request or as otherwise required.
                              • OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

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

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

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

                              Telehealth Behavioral Health consult

                              CVS Health Virtual Care™ telehealth consult

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

                                Applied Behavior Analysis (ABA)

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

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

                                Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care. You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

                                $30 per visit

                                $55 per outpatient visit

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

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

                                20% of plan allowance per admission

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

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

                                $55 per outpatient visit

                                Section 5(f). Prescription Drug Benefits

                                Important things you should keep in mind about these benefits:

                                • This is a five tier open formulary pharmacy plan, Advanced Control Formulary. The formulary is a list of drugs that your health plan covers. With your Advanced Control Formulary Pharmacy plan, each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Each tier has a separate out-of-pocket cost.
                                  • Preferred generic
                                  • Preferred brand
                                  • Non-preferred generic and brand
                                  • Preferred specialty
                                  • Non-preferred specialty

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

                                  • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
                                  • Where you can obtain them. You may fill non-emergency prescriptions at a participating Plan retail pharmacy or by mail order for up to a 90-day supply of medication (if authorized by your physician). You may obtain up to a 30-day supply of medication for one (1) copay, and for a 31-day up to a 90-day supply of medication for two (2) copays. In no event will the copay exceed the cost of the prescription drug. Please call Member Services at 800-537-9384 for more details on how to use the mail order program. Mail order is not available for drugs and medications ordered through a network specialty pharmacy. Prescriptions ordered through a network specialty pharmacy are only filled for up to a 30-day supply due to the nature of these prescriptions. In an emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. For retail pharmacy transactions, you must present your Aetna Member ID card at the point of sale for coverage. If you obtain an emergency prescription at a pharmacy that does not participate with the plan, you will need to pay the pharmacy the full price of the prescription and submit a claim for reimbursement subject to the terms and conditions of the plan.
                                  • We use an open managed formulary. The formulary is a list of drugs that your Plan covers. Drugs are prescribed by Plan doctors and dispensed in accordance with the 2024 Pharmacy Drug (Formulary) Guide. Certain drugs require your doctor to get precertification or step therapy from the Plan before they can be covered under the Plan. Your prescription drug plan includes drugs listed in the 2024 Pharmacy Drug (Formulary) Guide. Prescription drugs listed on the formulary exclusions list are excluded unless a medical exception is approved by the Plan. If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at www.aetnafeds.com/pharmacy.php to review our 2024 Pharmacy Drug (Formulary) Guide or call 800-537-9384.
                                  • Drugs not on the formulary. Formularies are developed and reviewed by the CVS Caremark Pharmacy and Therapeutics Committee, comprised of physicians, pharmacists and other clinicians that review drugs for inclusion in the formulary. They consider the drug’s effectiveness and safety in their evaluation. While most of the drugs on the non-formulary list are brand drugs, some generic drugs also may be on the non-formulary list. For example, this may happen when brand medications lose their patent and the FDA has granted a period of exclusivity to specific generic manufacturers. When this occurs, the price of the generic drug may not decrease as you might think most generic drugs do. This period of exclusivity usually ranges between 3-6 months. Once this time period expires, competition from other generic manufacturers will generally occur and this helps lower the price of the drug and this may lead the Plan to re-evaluate the generic for possible inclusion on the formulary. We will place some of these generic drugs that are granted a period of exclusivity on our non-formulary list, which requires the highest copay level. Remember, a generic equivalent will be dispensed, if available, unless your physician specifically requires a brand name and writes "Dispense as Written" (DAW) on the prescription, so discuss this with your doctor.
                                  • Choose generics. The Plan requires the use of generics if a generic drug is available. If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance* unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained from the Plan. Generics contain the same active ingredients in the same amounts as their brand name counterparts and have been approved by the FDA. By using generic drugs, you will see cost savings, without jeopardizing clinical outcome or compromising quality. *The differential/penalty will not apply to Plan accumulators (example: out-of-pocket maximum).
                                  • Precertification. Your pharmacy benefits plan includes precertification. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-approved by our Pharmacy Management Precertification Unit before they will be covered. Only your physician or pharmacist, in the case of an antibiotic or analgesic, can request precertification for a drug. Step-therapy is another type of precertification. Certain medications will be excluded from coverage unless you try one or more "step" drug(s) first, or unless a medical exception is obtained. The drugs requiring precertification or step-therapy are subject to change. Visit our website at www.aetnafeds.com for the most current information regarding the precertification and step-therapy lists. Ask your physician if the drugs being prescribed for you require precertification or step-therapy.
                                  • These are the dispensing limitations. Prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy or by mail order may be dispensed for up to a 90-day supply of medication (if authorized by your physician). You may obtain up to a 30-day supply of medication for one copay, and a 31-day up to a 90-day supply of medication for two copays. In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name.

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

                                  • A generic equivalent may be dispensed if it is available, and where allowed by law.
                                  • Specialty drugs. Specialty drugs are medications that treat complex, chronic diseases which includes select oral, injectable and infused medications. The first fill including all subsequent refills of these medications must be obtained through a network specialty pharmacy.

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

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

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

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

                                    Note: Certain drugs to treat Gender dysphoria and infertility are considered specialty drugs. Please see Specialty drugs in this section.

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

                                    $3 per Preferred Generic (PG) formulary drug;

                                    $35 per Preferred Brand (PB) name formulary drug; and

                                    50% up to $200 maximum per covered Non-Preferred (NP) (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:

                                    $6 (two copays) per Preferred Generic (PG) formulary drug;

                                    $70 (two copays) per Preferred Brand (PB) name formulary drug; and

                                    50% up to $400 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

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

                                    $10 per Preferred Generic (PG) formulary drug;

                                    50% up to $200 maximum per Preferred Brand (PB) name formulary drug; and

                                    50% up to $300 maximum per covered Non-Preferred (NP) (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 Preferred Generic (PG) formulary drug;

                                    50% up to $400 maximum per Preferred Brand (PB) name formulary drug; and

                                    50% up to $600 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

                                    Preventive Care Medications

                                    Medications to promote better health as recommended by ACA.

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

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

                                    • Aspirin
                                    • Folic acid supplements
                                    • Oral fluoride
                                    • Statins
                                    • Breast cancer prevention drugs
                                    • HIV PrEP
                                    • Nicotine Replacement Medications (Limits apply)
                                    • Bowel Prep Medications (Required with preventive Colonoscopy)

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

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

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

                                    Women's contraceptive drugs and devices

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

                                    Note: If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at
                                    www.aetnafeds.com/pharmacy.php to review our 2024 Pharmacy Drug (Formulary) Guide or call 800-537-9384.

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

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

                                    $35 per Preferred Brand (PB) name formulary drug; and

                                    50% up to $200 maximum per covered Non-Preferred (NP) (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:

                                    $70 (two copays) per Preferred Brand (PB) name formulary drug; and

                                    50% up to $400 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

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

                                    50% up to $200 maximum per Preferred Brand (PB) name formulary drug; and

                                    50% up to $300 maximum per covered Non-Preferred (NP) (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:

                                    50% up to $400 maximum per Preferred Brand (PB) name formulary drug; and

                                    50% up to $600 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

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

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

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

                                    Preferred Specialty (PSP): 50% up to $350 maximum

                                    Non-preferred Specialty (NPSP): 50% up to $700 maximum

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

                                    Preferred Specialty (PSP): 50% up to $350 maximum

                                    Non-preferred Specialty (NPSP): 50% up to $700 maximum

                                    Limited benefits:

                                    • Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period. Contact the Plan at 800-537-9384 for dose limits.

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

                                    $3 per Preferred Generic (PG) formulary drug;

                                    $35 per Preferred Brand (PB) name formulary drug; and

                                    50% up to $200 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

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

                                    $10 per Preferred Generic (PG) formulary drug;

                                    50% up to $200 maximum per Preferred Brand (PB) name formulary drug; and

                                    50% up to $300 maximum per covered Non-Preferred (NP) (generic or brand name) drug.

                                    • Drugs available without a prescription or forwhich there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law.
                                    • Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
                                    • Vitamins, unless otherwise stated (including prescription vitamins), nutritional supplements, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition when administered under the direction of a Plan doctor (please see Durable Medical Equipment in Section 5(a) for more information on what the plan will cover).
                                    • Medical supplies such as dressings and antiseptics
                                    • Lost, stolen or damaged drugs
                                    • Drugs for cosmetic purposes
                                    • Drugs to enhance athletic performance
                                    • Nonprescription medications unless specifically indicated elsewhere
                                    • Prophylactic drugs including, but not limited to, anti-malarials for travel
                                    • Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
                                    • Compounded thyroid hormone therapy

                                    Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See Section 5(a)). OTC drugs will not be covered unless you have a prescription and that prescription is presented at the pharmacy and processed through our pharmacy claim system.

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

                                    This prescription drug plan offers the Comprehensive Plus formulary which covers all drugs that CMS determines to be Part D and additionally, offers supplemental benefits for coverage of non-Part D drugs as outlined below.

                                    For access to our formulary, please visit:
                                    www.aetnafeds.com/pharmacy

                                    Non-Part D Supplemental Benefit:

                                    • Agents used for cosmetic purposes or hair growth.
                                    • Agents used to promote fertility.
                                    • Agents when used for the symptomatic relief of cough and colds.
                                    • Agents when used for the treatment of sexual or erectile dysfunction (ED).
                                    • Agents when used for weight loss.
                                    • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
                                    • Part B drugs.

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

                                    • Tier 1 Preferred Generic: $0 per drug at preferred/standard pharmacy;
                                    • Tier 2 Generic: $2 per drug at preferred pharmacy; $3 per drug at standard pharmacy;
                                    • Tier 3 Preferred Brand: $25 per drug at preferred/standard pharmacy;
                                    • Tier 4 Non-Preferred Brand: $75 per drug at preferred/standard pharmacy;
                                    • Tier 5 Specialty (Includes high-cost/unique generic and brand drugs): 25%, but not more than $150 per drug at preferred/standard pharmacy;

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

                                    • Tier 1 Preferred Generic: $0 per drug at preferred/standard pharmacy;
                                    • Tier 2 Generic: $4 per drug at preferred pharmacy; $6 per drug at standard pharmacy;
                                    • Tier 3 Preferred Brand: $50 per drug at preferred/standard pharmacy;
                                    • Tier 4 Non-Preferred Brand: $150 per drug at preferred/standard pharmacy;
                                    • Tier 5 Specialty: only available for 30 day supply

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

                                    • Tier 1 Preferred Generic: $0 per drug at preferred/standard pharmacy;
                                    • Tier 2 Generic: $4 per drug at preferred pharmacy; $5 per drug at standard pharmacy;
                                    • Tier 3 Preferred Brand: $40 per drug at preferred/standard pharmacy;
                                    • Tier 4 Non-Preferred Brand: $100 per drug at preferred/standard pharmacy;
                                    • Tier 5 Specialty (Includes high-cost/unique generic and brand drugs): 25%, but not more than $150 per drug at preferred/standard pharmacy;

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

                                    • Tier 1 Preferred Generic: $0 per drug at preferred/standard pharmacy;
                                    • Tier 2 Generic: $8 per drug at preferred pharmacy; $10 per drug at standard pharmacy;
                                    • Tier 3 Preferred Brand: $80 per drug at preferred/standard pharmacy;
                                    • Tier 4 Non-Preferred Brand: $200 per drug at preferred/standard pharmacy;
                                    • Tier 5 Specialty: only available for 30 day supply
                                    • Preventive drugs that are part of the Affordable Care Act. (A valid prescription is required.)
                                    • Narcan
                                    • Select drugs to treat cancer
                                    • Includes coverage of Part B covered diabetic supplies and vaccines
                                    • Tobacco Cessation drugs

                                    Medicare Part D Prescription Drug Plan – EGWP PDP includes a maximum out of pocket.

                                    Note: Once you reach the $2,000 out of pocket maximum for your prescription costs, you will pay $0 for the remainder of the calendar year for covered drugs under this Medicare Part D Prescription Drug Plan. This $2,000 will also apply to the Medical Plan’s total calendar year out-of-pocket maximum, see Section 4 for additional details on your Plan option out of pocket maximum.

                                    Section 5(g). Dental Benefits

                                    Important things you should keep in mind about these benefits:

                                    • You have two different dental options, Advantage Dental or Dental PPO, from which to choose. New members are automatically enrolled in the Advantage Dental option. If you would like to switch your option, you must call on or before the 15 th of the month for your coverage in the Dental PPO option to be effective on the first of the following month (i.e., call on 1/8 and your coverage is effective on 2/1, but if you call on 1/17, your coverage will not be effective until 3/1).
                                    • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
                                    • Under the AdvantageDental option, you must select a Plan primary care dentist before receiving care. Your selected Plan primary care dentist must provide or arrange covered care. Services rendered by non-Plan dentists are not covered. The Plan will cover 100% of the charges for the preventive, diagnostic and restorative procedures shown on the next page. You will be responsible for a copayment of $5 for each office visit regardless of the number of procedures performed.

                                    Note: You will be covered automatically under this Advantage Dental option unless you enroll in the Dental PPO option by calling Member Services at 800-537-9384.

                                    • Under the Dental PPO option, the Plan covers 100% of the charges (after satisfaction of a $20 annual deductible per member) for those preventive, diagnostic, and restorative procedures shown on the next page when using a participating network dentist. Participating network PPO dentists may offer members other services at discounted fees. Discounts may not be available in all sta tes. Providers are not required to honor the contracted rate/discount for dental services that are not covered or not in this section.
                                    • You also have the choice to use non-network dentists under this Dental PPO option for those preventive, diagnostic and restorative procedures shown on the next page, but the Plan will cover only 50% of the standard negotiated rate we would have paid an in-network PPO provider. You are responsible for any difference between the amount billed and the amount paid by the Plan for the eligible services listed in this section, plus your annual $20 deductible. Any other dental services rendered by non-network dentists are not covered.
                                    • We cover hospitalization for 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 not cover the dental procedure unless it is described on the next pages.
                                    • 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.

                                    Coverage is limited to palliative treatment and those services listed on the following schedule.

                                    Note: See Oral and maxillofacial surgery, section 5(b).

                                    Dental benefits begin on next page

                                    No deductible

                                    $20 per member per year.

                                    $20 per member per year.

                                    Diagnostic

                                    Office visit for routine oral evaluation — limited to 2 visits per year

                                    Bitewin g X-rays — limited to 2 sets of bitewing X-rays per year

                                    Complete X-ray series — limited to 1 complete X-ray series in any 3 year period

                                    Periapical X-rays and other dental X-rays — as necessary

                                    Preventive

                                    Prophylaxis (cleaning of teeth) — limited to 2 treatments per year

                                    Topical application of fluoride — limited to 2 courses of treatment per year to children under age 18

                                    Oral hygiene instruction (not covered under PPO)

                                    Restorative (Fillings)

                                    Amalgam/Composite 1 surface, primary or permanent

                                    Amalgam/Composite 2 surfaces, primary or permanent

                                    Amalgam/Composite 3 surfaces, primary or permanent

                                    Amalgam/Composite 4 or more surfaces, primary or permanent

                                    Prosthodontics Removable

                                    Denture adjustments (complete or partial/upper or lower)

                                    Endodontics

                                    Pulp cap — direct

                                    Pulp cap — indirect

                                    Advantage Dental Option

                                    Note: Advantage Dental option services shown in this section are only covered when provided by your selected participating primary care dentist in accordance with the terms of your Plan. If rendered by a participating specialist, they are provided at reduced fees. Pediatric dentists are considered specialists. Certain other services will be provided by your selected participating primary care dentist at reduced fees. Specific fees vary by area of the country. Call Member Services at 800-537-9384 for specific fees for your procedure. All member fees must be paid directly to the participating dentist. Services provided by a non-network dentist are not covered.

                                    Each employee and dependent(s) automatically will be enrolled in the Advantage Dental option, unless you enroll in the Dental PPO option.

                                    Each employee and dependent must select a primary care dentist from the directory when participating in the Basic Dental option and include the dentist’s name on the enrollment form. You also may call Member Services at 800-537-9384.

                                    Dental PPO

                                    Under this option, you have the choice to use our participating Dental PPO network dentists or a non-network dentist. The benefit levels are different, based on whether or not the dentist participates in our network. You must contact Member Services at 800-537-9384 to select this option.

                                    If you call on or before the 15 th of the month, your coverage in the Dental PPO option will be effective on the first of the following month (i.e., call on 1/8 and your coverage is effective on 2/1, but if you call on 1/17, your coverage will not be effective until 3/1).

                                    If you decide to switch back to the Basic Dental Option, you must call Member Services. The same timing rules apply. You must also select a Primary Care Dentist. Your prior Primary Care Dentist will not be reassigned to you, unless you specifically request it.

                                    Dental PPO In-Network Option

                                    The plan covers 100% of the charges (after satisfaction of the $20 annual deductible per member) for those preventive, diagnostic, and restorative procedures shown on the previous page when using a participating network dentist. Participating network PPO dentists may offer members other services at discounted fees. Discounts may not be available in all states. Please call Member Services at 800-537-9384 for specific fees for your procedure.

                                    Dental PPO Non-Network Option

                                    Dentists’ normal fees generally are higher than Aetna’s negotiated fees. Non-participating dentists will be paid only for those services shown on the previous page. Payment will be based on the standard negotiated rate provided to participating general dentists in the same geographic area. Members may be balance billed by the dentist for the difference between the dentist’s usual fee and the amount paid by the Plan.

                                    Section 5. Aetna Saver Option Benefits

                                    See Section 2 for how our benefits changed this year. See Summary of Benefits for a benefits summary of each option. Make sure that you review the benefits that are available under the option in which you are enrolled.

                                    (Page numbers solely appear in the printed brochure)

                                    • Section 5. Aetna Saver Option Benefits Overview
                                    • Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals
                                    • Diagnostic and treatment services
                                    • Telehealth services
                                    • Lab, X-ray and other diagnostic tests
                                    • Preventive care, adult
                                    • Preventive care, children
                                    • Maternity care
                                    • Family planning
                                    • Infertility services
                                    • Allergy care
                                    • Treatment therapies
                                    • Physical and occupational therapies
                                    • Pulmonary and cardiac rehabilitation
                                    • Habilitative therapy
                                    • Speech therapy
                                    • Hearing services (testing, treatment, and supplies)
                                    • Vision services (testing, treatment, and supplies)
                                    • Foot care
                                    • Orthopedic and prosthetic devices
                                    • Durable medical equipment (DME)
                                    • Home health services
                                    • Chiropractic
                                    • Alternative medicine treatments
                                    • Educational classes and programs
                                    • Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals
                                    • Surgical procedures
                                    • Reconstructive surgery
                                    • Oral and maxillofacial surgery
                                    • Organ/tissue transplants
                                    • Anesthesia
                                    • Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
                                    • Inpatient hospital
                                    • Outpatient hospital or ambulatory surgical center
                                    • Extended care benefits/Skilled nursing care facility benefits
                                    • Hospice care
                                    • Ambulance
                                    • Section 5(d). Emergency Services/Accidents
                                    • Emergency within our service area
                                    • Emergency outside our service area
                                    • Telehealth services
                                    • Ambulance
                                    • Section 5(e). Mental Health and Substance Use Disorder Benefits
                                    • Professional services
                                    • Diagnostics
                                    • Inpatient hospital or other covered facility
                                    • Outpatient hospital or other covered facility
                                    • Not covered
                                    • Section 5(f). Prescription Drug Benefits
                                    • Covered medications and supplies
                                    • Section 5(g). Dental Benefits
                                    • Accidental injury benefit
                                    • Section 5(h). Wellness and Other Special Features
                                    • Flexible benefits option
                                    • Aetna Member Website
                                    • Services for deaf and hearing-impaired
                                    • 24-Hour Nurse Line
                                    • Enhanced Maternity Program:
                                    • National Medical Excellence Program
                                    • Reciprocity benefit
                                    • Summary of Benefits for the Aetna Saver Plan - 2024

                                    Section 5. Aetna Saver Option Benefits Overview

                                    This Plan offers a Saver Option. The benefit package is described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

                                    The Saver Option Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also, read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about our Saver Option benefits, contact us at 800-537-9384 or on our website at www.aetnafeds.com.

                                    The Saver Option offers:

                                    • You must use participating providers in our network, in order to receive benefits.
                                    • Easy to use lower cost plan.
                                    • No Referrals (Open Access).
                                    • Services covered under this plan are subject to coinsurance which means we pay a percentage and you pay a percentage of our negotiated rates with our network providers to keep costs down.
                                    • $0 copay (no deductible) for preventive services like flu shots and physicals.

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

                                    Important things you should keep in mind about these benefits:

                                    • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                                    • The deductible is $1,000 Self Only or $2,000 for Self Plus One or Self and Family enrollment for Saver Option each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this section.
                                    • Plan physicians must provide or arrange your care.
                                    • A facility cost sharing applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
                                    • Be sure to read Section 4, You r Costs for Covered Services , for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                                    • You must use Participating providers in our network in order to receive benefits. We recommend that you select a PCP by calling Member Services at 800-537-9384.
                                    • The coverage and cost-sharing listed below are for services provided by physicians and other health care professionals for your medical care. See Section 5(c) for cost-sharing associated with the facility (i.e., hospital, surgical center, etc.).

                                    If you live or work in our service area, you do not have to obtain a referral from your PCP to see a network specialist.

                                    Professional services of physicians (PCP or Specialist)

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

                                      30% of our plan allowance

                                      30% of our plan allowance

                                      30% of our plan allowance

                                      30% of our plan allowance

                                      30% of the consult fee

                                      $55 per consult until the deductible is met, $0 per consult after deductible has been met

                                      Please see www.aetnafeds.com/tools.php for information on medical and behavioral telehealth services.

                                      Members will receive a welcome kit explaining the telehealth benefits.

                                      Refer to Section 5(e) for behavioral health telehealth consults.

                                      • Blood tests
                                      • Urinalysis
                                      • Non-routine pap tests
                                      • Pathology
                                      • X-rays
                                      • Non-routine mammograms
                                      • Ultrasound
                                      • Electrocardiogram and electroencephalogram (EEG)
                                      • Sleep Studies

                                      30% of our plan allowance

                                      Diagnostic tests limited to:

                                      • Bone density tests - diagnostic
                                      • CT scans/MRIs/PET scans
                                      • Diagnostic angiography
                                      • Genetic testing - diagnostic*
                                      • Nuclear medicine

                                      Note: The services need precertification. See Section 3 "Services requiring our prior approval".

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

                                      30% of our plan allowance

                                      *Note: Requires precertification. See Section 3 "Services requiring our prior approval".

                                      Nothing (no deductible)

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

                                      • Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
                                      • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://shorturl.at/hovHM.
                                      • Individual counseling on prevention and reducing health risks
                                      • Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at
                                        https://www.healthcare.gov/preventive-care-women/
                                      • To build your personalized list of preventive services go to https://health.gov/myhealthfinder
                                      • Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

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

                                      Nothing (no deductible)

                                      Routine mammogram - covered

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

                                      Nothing (no deductible)

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

                                      Nothing (no deductible)

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

                                      Nothing (no deductible)

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

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

                                      Nothing (no deductible)

                                      • Well-child care charges for routine examinations, immunizations and care (up to age 22)
                                        • Seven (7) routine exams to from birth age 12 months
                                        • Three (3) routine exams from age 12 months to 24 months
                                        • Three (3) routine exams from age 24 months to 36 months
                                        • One (1) routine exam per year thereafter to age 22
                                        • Vision screenings through age 17 to determine the need for vision correction*
                                        • Hearing exams through age 17 to determine the need for hearing correction
                                        • Routine examinations done on the day of immunizations (up to age 22)

                                        *For routine eye refraction, see Vision Services

                                        Nothing (no deductible)

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

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

                                        Complete maternity (obstetrical) care, such as:

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

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

                                        • Amniocentesis
                                        • Certain Pregnancy diagnostic lab tests
                                        • Delivery including Anesthesia
                                        • Fetal Stress Tests
                                        • High Risk Specialist Visits
                                        • Inpatient admissions
                                        • Ultrasounds

                                        Note: Here are some things to keep in mind:

                                        • You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
                                        • You may remain in the hospital up to three (3) days after a vaginal delivery and five (5) days after a cesarean delivery. We will extend your inpatient stay if medically necessary, but you, your representative, your participating doctor, or your hospital must precertify the extended stay.
                                        • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay including the initial examination of a newborn child covered under a Self Only, Self Plus One or Self and Family enrollment. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
                                        • We pay hospitalization and surgeon services for maternity care (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

                                        Note: Also see our Enhanced Maternity Program in Section 5 (h).

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

                                        Nothing (no deductible) for routine prenatal care or the first postpartum care visit when services are rendered by an in-network delivering health care provider, 30% of our Plan allowance for postpartum care visits thereafter.

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

                                        Breastfeeding support, supplies and counseling for each birth

                                        Nothing (no deductible)

                                        Not covered: Home births

                                        A range of voluntary family planning services limited to:

                                        • Contraceptive counseling on an annual basis
                                        • Surgically implanted contraceptives
                                        • Generic injectable contraceptive drugs, such as Depo-Provera
                                        • Intrauterine devices (IUDs)
                                        • Diaphragms
                                        • Tubal ligation

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

                                        Nothing (no deductible)

                                        Nothing (no deductible) for women

                                        For men: 30% of our plan allowance

                                        • Reversal of voluntary surgical sterilization
                                        • Genetic testing and counseling

                                        Infe rtility is a disease defined as when a person is unable to conceive or produce conception after one year of egg-sperm contact when the individual attempting conception is under 35 years of age, or after six months of egg-sperm contact when the individual attempting conception is 35 years of age or older. Egg-sperm contact can be achieved by regular sexual intercourse or artificial insemination (intrauterine, intracervical, or intravaginal) as stated in our medical clinical policy bulletin (see Section 10. for definition of Medical Necessity for additional details on Aetna’s Clinical Policy). This definition applies to all individuals regardless of sexual orientation or the presence/availability of a reproductive partner. Infertility may also be established by the demonstration of a disease or condition of the reproductive tract such that egg-sperm contact would be ineffective.

                                        Diagnosis and treatment of infertility, such as:

                                        • Testing for diagnosis and surgical treatment of the underlying medical cause of infertility.
                                        • Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease.* **

                                        Comprehensive Infertility Services

                                        • Artificial insemination (AI)* ** and monitoring of ovulation:
                                          • Intracervical insemination (ICI)
                                          • Intrauterine insemination (IUI)
                                          • Intravaginal insemination (IVI)

                                          Note: We limit Artificial Insemination to 3 cycles per calendar year. The Plan defines a “cycle” as:

                                          • An attempt at ovulation induction while on injectable medication to stimulate the ovaries with or without artificial insemination
                                          • An artificial insemination cycle with or without injectable medication to stimulate the ovaries
                                          • Ovulation induction cycle(s) while on injectable medication to stimulate the ovaries. *
                                          • Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician *
                                          • Injectable fertility drugs including but not limited to menotropins, hCG, GnRH agonists, and intravenous immunoglobulins (IVIG). (See Section 5f for coverage)*

                                          You are eligible for these covered services if:

                                          • You or your partner have been diagnosed with infertility.
                                          • You have met the requirement for the number of months trying to conceive through egg and sperm contact.
                                          • Your unmedicated day 3 Follicle Stimulating Hormone (FSH) level and testing of ovarian responsiveness meet the criteria outlined in Aetna’s infertility clinical policy.

                                          Note: The Plan does not cover infertility drugs under the medical benefit. See Section 5(f) for coverage.

                                          Aetna’s National Infertility Unit

                                          Our NIU is here to help you and is staffed by a dedicated team of registered nurses and infertility coordinators. They can help you with understanding your benefits and the medical precertification process. You can learn more at www.aetnainfertilitycare.com or call the NIU at 1-800-575-5999 (TTY: 711).

                                          * Subject to medical necessity

                                          ** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384. Your network provider will request approval from us in advance for your infertility services. If your provider is not a network provider, you are responsible to request approval from us in advance.

                                          50% of our plan allowance

                                          Note: Your out of pocket costs for infertility services do not count towards your out-of-pocket maximum (See Section 4 for details)

                                          All infertility services associated with or in support of an Advanced Reproductive Technology (ART) cycle. These include, but are not limited to:

                                          • Imaging, laboratory services, and professional services
                                          • In vitro fertilization (IVF)
                                          • Zygote intrafallopian transfer (ZIFT)
                                          • Gamete intrafallopian transfer (GIFT)
                                          • Cryopreserved embryo transfers
                                          • Gestational carrier cycles
                                          • Any related services, products or procedures (such as intracytoplasmic sperm injection (ICSI) or ovum microsurgery).
                                          • Cryopreservation (freezing), storage or thawing of eggs, embryos, sperm or reproductive tissue (unless noted as covered)
                                          • All charges associated with or in support of surrogacy arrangements for you or the surrogate. A surrogate is a female carrying her own genetically related child with the intention of the child being raised by someone else, including the biological father
                                          • Infertility services that are not reasonably likely to result in success
                                          • Anychargesassociated with care required to obtain ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for ART procedures except as stated above
                                          • The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers (or surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational carrier
                                          • Reversal of sterilization surgery.
                                          • Treatmentfor infertility when the cause of the infertility was a previous sterilization with or without surgical reversal.This includes tubal ligation, hysterectomy and vasectomy only if obtained as a form of voluntary sterilization
                                          • Servicesand supplies related to the above mentioned services, including sperm processing
                                          • Cost of home ovulation predictor kits or home pregnancy kits
                                          • Drugsrelated to the treatment of non-covered benefits
                                          • Infertility services that are not reasonably likely to result in success
                                          • Elective fertility preservation, such as egg freezing sought due to natural aging;
                                          • Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention
                                          • Storage costs
                                          • Obtaining sperm from a person not covered under this plan
                                          • Infertility treatment when a successful pregnancy could have been obtained through less costly treatment
                                          • Infertility treatment when infertility is due to a natural physiologic process such as age related ovarian insufficiency (e.g. perimenopause, menopause)as measured by an unmedicated FSH level at or above 19 on cycle day two or three of your menstrual period or other abnormal testing results as outlined in Aetna’s infertility clinical policy
                                          • Oral and Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH agonists. (except where otherwise noted in Section 5f)
                                          • Any infertility service rendered that requires precertification without a prior authorization
                                          • Coverage for services received by a spouse or partner who is not a covered member under the plan

                                          Note: You pay the applicable cost share for each visit to a doctor’s office including each visit to a nurse for an injection.

                                          30% of our plan allowance

                                          30% of our plan allowance

                                          Not covered: Provocative food testing and sublingual allergy desensitization

                                          Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants in Section 5(b).

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

                                          Note: Growth hormone therapy is covered under Medical Benefits; office cost sharing applies. We cover growth hormone injectables under the prescription drug benefit.

                                          Note: We will only cover GHT when we preauthorize the treatment. Call 800-245-1206 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information and it is authorized by Aetna. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

                                          Applied Behavior Analysis - (see Section 5(e) for benefits)

                                          30% of our plan allowance

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

                                          • Qualified Physical therapists
                                          • Occupational therapists

                                          Note: We only cover therapy when a physician:

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

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

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

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

                                          30% of our plan allowance

                                          • Long-term rehabilitative therapy

                                          30% of our plan allowance

                                          Not Covered: Long-term rehabilitative therapy

                                          Note: No day or visit limit applies.

                                          30% of our plan allowance

                                          60 visits per person, per calendar year

                                          Note: For children up to age 19, no day or visit limit applies for habilitative therapy, see section 5(a) Habilitative therapy.

                                          30% of our plan allowance

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

                                          30% of our plan allowance

                                          • Allother hearing testing not medically necessary
                                          • Hearingservicesthat are not shown as covered
                                          • Hearing aids

                                          30% of our plan allowance

                                          30% of our plan allowance

                                          • Fitting of contact lenses
                                          • Visiontherapy,including eye patches and eye exercises, e.g., orthoptics, pleoptics, for the treatment of conditions related to learning disabilities or developmental delays
                                          • Radial keratotomy and laser eye surgery, including related procedures designed to surgically correct refractive errors

                                          Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

                                          30% of our plan allowance

                                          • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
                                          • Treatmentof weak, strained or flat feet; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open manipulation or fixation)
                                          • Footorthotics
                                          • Podiatric shoe inserts
                                          • Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes. Limb and torso prosthetics must be preauthorized.
                                          • Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.
                                          • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
                                          • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
                                          • Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

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

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

                                          Note: For information on the professional charges for the surgery to insert an implant or internal prosthetic device, see Section 5(b) Surgical procedures. For information regarding facility fees associated with obtaining orthopedic and prosthetic devices, see Section 5(c).

                                          30% of our plan allowance

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

                                          Nothing up to Plan lifetime maximum of $500

                                          • Orthopedicand corrective shoes, arch supports, foot orthotics, heel pads and heel cups
                                          • Lumbosacral supports
                                          • All charges over $500 for hair prosthesis

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

                                          • Oxygen
                                          • Dialysis equipment
                                          • Hospital beds (Clinitron and electric beds must be preauthorized)
                                          • Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
                                          • Crutches
                                          • Walkers
                                          • Insulin pumps and related supplies such as needles and catheters
                                          • Medical foods taken for the treatment of Inborn Errors of Metabolism when provided by a participating DME provider and administered under the direction of a physician

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

                                          30% of our plan allowance

                                          • Elastic stockings and support hose
                                          • Bathroom equipment such as bathtub seats, benches, rails and lifts
                                          • Homemodifications such as stair glides, elevators and wheelchair ramps
                                          • Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities
                                          • Medical foods that do not require a prescription under Federal law even if your physician or other health care professional prescribes them
                                          • Nutritional supplements that are not administered by catheter or nasogastric tubes, except for oral medical foods taken for the treatment of Inborn Errors of Metabolism when administered under the direction of a physician
                                          • Home health services ordered by a Plan Physician and provided by nurses and home health aides through a participating home health care agency. Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to one (1) visit per day with each visit equal to a period of four (4) hours or less. The plan will allow up to 60 visits per member per calendar year. Your Plan Physician will periodically review the program for continuing appropriateness and need.
                                          • Services include oxygen therapy.

                                          30% of our plan allowance

                                          Intravenous (IV) Infusion Therapy and medications

                                          30% of our plan allowance

                                          Note: Short-term physical, speech, or occupational therapy accumulate toward the applicable benefit limit (See the physical, speech and occupational therapy benefits in this section).

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

                                          • Nursingcare for the convenience of the patient or the patient’s family.
                                          • Custodial care, i.e. home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative and appropriate for the active treatment of a condition, illness, disease or injury.
                                          • Servicesprovided by a family member or resident in the member’s home.
                                          • Servicesrendered at any site other than the member’s home.
                                          • Servicesrendered when the member is not homebound because of illness or injury.
                                          • Privateduty nursing services.
                                          • Transportation.

                                          Chiropractic services up to 20 visits per member per calendar year

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

                                          30% of our plan allowance

                                          • Any services not listed above

                                          Acupuncture - 10 visits per member per calendar year (when considered medically necessary)

                                          Note: See Section 5(b) for our coverage of acupuncture when provided as anesthesia for covered surgery.

                                          See Section 5 Non-FEHB benefits available to Plan members for discount arrangements.

                                          30% of plan allowance (after deductible)

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

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

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

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

                                          Nothing (no deductible)

                                          Coverage is provided for:

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

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

                                          Nothing (no deductible) for four (4) smokin g cessation counseling sessions per quit attempt and two (2) quit attempts per year.

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

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

                                          Important things you should keep in mind about these benefits:

                                          • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                                          • The deductible is $1,000 Self Only or $2,000 for Self Plus One or Self and Family enrollment for Saver Option each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this section.
                                          • 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.
                                          • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, etc.).
                                          • You must use Participating providers in our network in order to receive benefits. We recommend that you select a PCP by calling Member Services at 800-537-9384.

                                          YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

                                          A comprehensive range of services, such as:

                                          • Operative procedures
                                          • Treatment of fractures, including casting
                                          • Normal pre- and post-operative care by the surgeon
                                          • Correction of amblyopia and strabismus
                                          • Endoscopy procedures
                                          • Biopsy procedures
                                          • Removal of tumors and cysts
                                          • Correction of congenital anomalies (See Reconstructive surgery)
                                          • Surgical treatment of severe obesity (bariatric surgery) – a condition in which an individual has a body mass index (BMI) exceeding 40 or a BMI greater than 35 in conjunction with documented significant co-morbid conditions (such as coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea, nonalcoholic steatohepatitis (NASH) or refractory hypertension).**
                                            • Members must have attempted weight loss in the past without successful long-term weight reduction; and Members must have participated in and been compliant with an intensive multicomponent behavioral intervention through a combination of dietary changes and increased physical activity for 12 or more sessions occurring within 2 years prior to surgery. Blood glucose control must be optimized, and psychological clearance may be necessary.
                                            • Open or laparoscopic Roux-en-Y gastric bypass; or
                                            • Open or laparoscopic biliopancreatic diversion with or without duodenal switch; or
                                            • Sleeve gastrectomy; or
                                            • Laparoscopic adjustable silicone gastric banding (Lap-Band) procedures.
                                            • Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information

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

                                            • Voluntary sterilization for men (e.g., vasectomy)
                                            • Treatment of burns
                                            • Skin grafting and tissue implants
                                            • Gender affirming surgery*

                                            The Plan will provide coverage for the following when the member meets Plan criteria:

                                            - Surgical removal of breasts**
                                            - Breast augmentation (implants/lipofilling)**
                                            - Surgical removal of uterus, ovaries and testes**
                                            - Reconstruction of external genitalia**
                                            -Medically necessary facial gender affirming surgery and body contouring (Note: For more information on coverage details for medically necessary facial and body contouring coverage and criteria, please refer to www.aetnafeds.com/gender-affirming-care)

                                            * Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

                                            ** Subject to medical necessity based on our clinical policy bulletin.

                                            Note: Hormone therapy is covered under Section 5(f), Prescription drug benefits. Prior authorization is required.

                                            30% of our Plan allowance

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

                                            Nothing (no deductible)

                                            • Reversal of voluntary surgically-induced sterilization
                                            • Surgeryprimarily for cosmetic purposes
                                            • Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
                                            • Routine treatment of conditions of the foot; (see Foot care)
                                            • Gender reassignment services that are not considered medically necessary
                                            • Surgery to correct a functional defect
                                            • Surgery to correct a condition caused by injury or illness if:
                                              • the condition produced a major effect on the member’s appearance and
                                              • the condition can reasonably be expected to be corrected by such surgery
                                              • surgery to produce a symmetrical appearance of breasts
                                              • treatment of any physical complications, such as lymphedema
                                              • breast prostheses and surgical bras and replacements (SeeProsthetic devices)

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

                                              30% of our Plan allowance

                                              Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

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

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

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

                                              30% of our Plan allowance

                                              • Dentalimplants
                                              • Dental care (such as restorations) involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

                                              These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Section 3, Other services under You need prior Plan approval for certain services.

                                              • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
                                              • Cornea
                                              • Heart
                                              • Heart/lung
                                              • Intestinal transplants
                                                • Isolated small intestine
                                                • Small intestine with the liver
                                                • Small intestine with multiple organs, such as the liver, stomach, and pancreas

                                                30% of our Plan allowance

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

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

                                                  30% of our Plan allowance

                                                  Blood or marrow stem cell transplants

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

                                                  30% of our Plan allowance

                                                  The Plan extends coverage for the diagnoses as indicated below.

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

                                                    *Approved clinical trial necessary for coverage.

                                                    30% of our Plan allowance

                                                    These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence.

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

                                                    • Allogeneic transplants for:
                                                      • Advanced Hodgkin's lymphoma
                                                      • Advanced non-Hodgkin's lymphoma
                                                      • Beta Thalassemia Major
                                                      • Chronic inflammatory demyelination polyneuropathy (CIDP)
                                                      • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
                                                      • Multiple myeloma
                                                      • Multiple sclerosis
                                                      • Sickle Cell anemia
                                                      • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
                                                      • Advanced Hodgkin’s lymphoma
                                                      • Advanced non-Hodgkin’s lymphoma
                                                      • Breast cancer
                                                      • Chronic lymphocytic leukemia
                                                      • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
                                                      • Chronic myelogenous leukemia
                                                      • Colon cancer
                                                      • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
                                                      • Multiple myeloma
                                                      • Multiple sclerosis
                                                      • Myelodysplasia/Myelodysplastic Syndromes
                                                      • Myeloproliferative disorders (MPDs)
                                                      • Non-small cell lung cancer
                                                      • Ovarian cancer
                                                      • Prostate cancer
                                                      • Renal cell carcinoma
                                                      • Sarcomas
                                                      • Sickle Cell anemia
                                                      • Advanced Childhood kidney cancers
                                                      • Advanced Ewing sarcoma
                                                      • Advanced Hodgkin's lymphoma
                                                      • Advanced non-Hodgkin's lymphoma
                                                      • Aggressive non-Hodgkin's lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/ lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
                                                      • Breast cancer
                                                      • Childhood rhabdomyosarcoma
                                                      • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
                                                      • Chronic myelogenous leukemia
                                                      • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
                                                      • Epithelial ovarian cancer
                                                      • Mantle Cell (Non-Hodgkin lymphoma)
                                                      • Multiple sclerosis
                                                      • Scleroderma
                                                      • Scleroderma-SSc (severe, progressive)
                                                      • Small cell lung cancer
                                                      • Systemic lupus erythematosus
                                                      • Systemic sclerosis

                                                      30% of our Plan allowance

                                                      • NationalTransplantProgram(NTP) - Transplants which are non-experimental or non- investigational are a covered benefit. Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery. The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures. A transplant is non-experimental and non- investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate treatment for your specific condition. Coverage for a transplant where you are the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.

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

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

                                                      Clinical trials must meet the following criteria:

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

                                                      b. All of the following criteria must be met:

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

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

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

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

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

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

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

                                                      4. The member must:

                                                      a. Not be treated “off protocol,” and

                                                      b. Must actually be enrolled in the trial.

                                                      30% of our Plan allowance

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

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

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

                                                      Note: For sedation or anesthesia relating to dental services performed in a dental office, see Section 5 (g), Dental benefits.

                                                      Note: When the anesthesiologist is the primary giver of services, such as for pain management, the specialist cost sharing applies.

                                                      30% of our Plan allowance

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

                                                      Important things you should keep in mind about these benefits:

                                                      • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                                                      • The deductible is $1,000 Self Only or $2,000 for Self Plus One or Self and Family enrollment for Saver Option each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this section.
                                                      • Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
                                                      • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                                                      • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
                                                      • You must use Participating providers in our network in order to receive benefits. We recommend that you select a PCP by calling Member Services at 800-537-9384.
                                                      • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.

                                                      Except in emergencies, all hospital admissions and select outpatient surgery require precertification from your participating physician and prior authorization from Aetna. Please refer to Section 3 to be sure which services require precertification.

                                                      Room and board, such as

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

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

                                                      Other hospital services and supplies, such as:

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

                                                      30% of our Plan allowance

                                                      • Whole blood and concentrated red blood cells not replaced by the member
                                                      • Non-coveredfacilities, such as nursing homes, schools
                                                      • Custodial care, rest cures, domiciliary or convalescent cares
                                                      • Personalcomfort items, such as phone and television
                                                      • Private nursing care
                                                      • Operating, recovery, and other treatment rooms
                                                      • Prescribed drugs and medications
                                                      • Radiologic procedures, diagnostic laboratory tests, and X-ray s when associated with a medical procedure being done the same day
                                                      • Pathology Services
                                                      • Administration of blood, blood plasma, and other biologicals
                                                      • Blood products, derivatives and components, artificial blood products and biological serum
                                                      • Pre-surgical testing
                                                      • Dressings, casts, and sterile tray services
                                                      • Medical supplies, including oxygen
                                                      • Anesthetics and anesthesia service
                                                      • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.

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

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

                                                      Note: Preventive care services are not subject to cost sharing listed.

                                                      30% of our Plan allowance

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

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

                                                      *See below for exceptions

                                                      Note: Preventive care services are not subject to cost sharing listed.

                                                      30% of our Plan allowance

                                                      Complex diagnostic tests limited to:

                                                      • Bone density tests - diagnostic
                                                      • CT scans/MRIs/PET scans
                                                      • Diagnostic angiography
                                                      • Genetic testing - diagnostic*
                                                      • Nuclear medicine

                                                      Note: These services need precertification. See Section 3, "Services requiring our prior approval".

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

                                                      30% of our Plan allowance

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

                                                      Extended care benefit: All necessary services during confinement in a skilled nursing facility with a 60­ day limit per calendar year when full-time nursing care is necessary and the confinement is medically appropriate as determined by a Plan doctor and approved by the Plan.

                                                      30% of our Plan allowance

                                                      Not covered: Custodial care

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

                                                      30% of our Plan allowance

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

                                                      1. Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or
                                                      2. To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or
                                                      3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
                                                      4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

                                                      30% of our Plan allowance

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

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

                                                      Section 5(d). Emergency Services/Accidents

                                                      Important things you should keep in mind about these benefits:

                                                      • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                                                      • The deductible is $1,000 Self Only or $2,000 for Self Plus One or Self and Family enrollment for Saver Option each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this section.
                                                      • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                                                      • You must use Participating providers in our network in order to receive benefits. We recommend that you select a PCP by calling Member Services at 800-537-9384.
                                                      • We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.

                                                      What is a medical emergency?

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

                                                      What to do in case of emergency: Emergencies within our Service Area:

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

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

                                                      • Call the local emergency hotline (e.g., 911) or go to the nearest emergency facility. For non-emergency services, care may be obtained from a retail clinic, a walk-in clinic, an urgent care center or by calling Teladoc. If a delay would not be detrimental to your health, call your primary care 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 provider so t hey can assist the treating physician by supplying information about your medical history.
                                                      • If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Aetna as soon as possible.

                                                      Emergencies outside our Service Area:

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

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

                                                      Follow-up Care after Emergencies

                                                      All follow-up care should be coordinated by your PCP or network specialist. Follow-up care with non-participating providers is only covered with a referral from your primary care provider and pre-approval from Aetna. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care.

                                                      30% of our Plan allowance

                                                      30% of our Plan allowance

                                                      • Emergency or urgent care as an outpatient at a hospital (Emergency Room) including doctors' services.

                                                      30% of our Plan allowance

                                                      Not covered: Elective care or non-emergency care

                                                      30% of our Plan allowance

                                                      30% of our Plan allowance

                                                      • Emergency or urgent care as an outpatient at a hospital (Emergency Room), including doctors' services.

                                                      30% of our Plan allowance

                                                      • Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
                                                      • Emergencycare provided outside the service area if the need for care could have been foreseen before leaving the service area
                                                      • Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.

                                                      30% of the consult fee

                                                      $55 per consult until the deductible is met, $0 per consult after deductible has been met

                                                      Please see www.aetnafed.com/tools.php for information on medical and behavioral telehealth services.

                                                      Members will receive a welcome kit explaining the telehealth benefits.

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

                                                      1. Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or
                                                      2. To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or
                                                      3. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
                                                      4. To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.

                                                      Air and sea ambulance may be covered. Prior approval is required.

                                                      Note: See 5(c) for non-emergency service.

                                                      30% of our Plan allowance

                                                      • Ambulancetransportation to receive outpatient or inpatient services and back home again, except in an emergency.
                                                      • Ambuletteservice
                                                      • Airambulance without prior approval
                                                      • Ambulancetransportation for member convenience or for reasons that are not medically necessary.

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

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

                                                      Important things you should keep in mind about these benefits:

                                                      • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
                                                      • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                                                      • The deductible is $1,000 Self Only or $2,000 for Self Plus One or Self and Family enrollment for Saver Option each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this section.
                                                      • YOUMUST GET PREAUTHORIZATION FOR CERTAIN SERVICES. Benefits are payable only when we determine the care is clinically appropriate to treat your condition. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan. Please see Section 3 of this brochure for a list of services that require preauthorization.
                                                      • Aetna can assist you in locating participating providers in the Plan, unless your needs for covered services extend beyond the capability of the affiliated providers. Emergency care is covered (See Section 5(d), Emergency services/accidents). You can receive information regarding the appropriate way to access the behavioral health care services that are covered under your specific plan by calling Member Services at 800-537-9384. A referral from your PCP is not necessary to access behavioral health care but your PCP may assist in coordinating your care.
                                                      • We will provide medical review criteria for denials to enrollees, members or providers upon request or as otherwise required.
                                                      • OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.
                                                      • You must use Participating providers in our network in order to receive benefits. We recommend that you select a PCP by calling Member Services at 800-537-9384.

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

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

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

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

                                                      30% of our Plan allowance

                                                      Telehealth Behavioral Health consult

                                                      30% of our Plan allowance

                                                      CVS Health Virtual Care™ telehealth consult

                                                      30% of our Plan allowance

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

                                                        30% of our Plan allowance

                                                        Applied Behavior Analysis (ABA)

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

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

                                                        Note: Requires Precertification . See Section 3 “Services requiring ou r prior approval”. You are responsible for ensuring that we are asked to precertify your care. You should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 800-537-9384.

                                                        30% of our Plan allowance

                                                        30% of our Plan allowance

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

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

                                                        30% of our Plan allowance

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

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

                                                        30% of our Plan allowance

                                                        Section 5(f). Prescription Drug Benefits

                                                        Important things you should keep in mind about these benefits:

                                                        • This is a two tier closed formulary pharmacy plan, High Value Formulary. The formulary is a list of drugs that your health plan covers. With your High Value Formulary Pharmacy Plan, each drug is grouped as a generic or a brand. Each tier has a separate out-of-pocket cost.
                                                          • Preferred generic
                                                          • Preferred brand
                                                          • We cover prescribed drugs and medications, as described in the chart beginning on the next page.
                                                          • The deductible is $1,000 Self Only or $2,000 for Self Plus One or Self and Family enrollment for Saver Option each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this section.
                                                          • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
                                                          • Your prescribers must obtain prior approval/precertification for certain prescription drugs and supplies before coverage applies. Prior approval/precertifications must be renewed periodically.
                                                          • Federal law prevents the pharmacy from accepting unused medications.
                                                          • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                                                          • Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. Upon approval by the Plan, the prescription is covered for the current calendar year or a specified time period, whichever is less
                                                          • During the course of the year, we may move a brand-name drug from Tier 2 (preferred brand-name, preferred generic specialty and preferred brand-name specialty drugs) to non-covered if there is a change in manufacturer contracting, a generic equivalent or biosimilar becomes available or if new safety concerns arise. If your drug is moved to non-covered, you pay the full cost of the medication. Tier reassignments during the year are not considered benefit changes.
                                                          • You must use Participating providers in our network in order to receive benefits. We recommend that you select a PCP by calling Member Services at 800-537-9384.

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

                                                          • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice.
                                                          • Where you can obtain them. You may fill non-emergency prescriptions at a participating Plan retail pharmacy or by mail order for up to a 90-day supply of medication (if authorized by your physician). In no event will the copay exceed the cost of the prescription drug. Please call Member Services at 800-537-9384 for more details on how to use the mail order program. Mail order is not available for drugs and medications ordered through a network specialty pharmacy. Prescriptions ordered through a network specialty pharmacy are only filled for up to a 30-day supply due to the nature of these prescriptions. In an emergency or urgent care situation, you may fill your covered prescription at any retail pharmacy. For retail pharmacy transactions, you must present your Aetna Member ID card at the point of sale for coverage. If you obtain an emergency prescription at a pharmacy that does not participate with the plan, you will need to pay the pharmacy the full price of the prescription and submit a claim for reimbursement subject to the terms and conditions of the plan.
                                                          • We use a closed managed formulary. The formulary is a list of drugs that your Plan covers. Drugs are prescribed by Plan doctors and dispensed in accordance with the 2024 Pharmacy Drug (Formulary) Guide. Certain drugs require your doctor to get precertification or requires step therapy before they can be covered under the Plan. Your prescription drug plan includes drugs listed in the 2024 Pharmacy Drug (Formulary) Guide. Visit our website at
                                                            www.aetnafeds.com/pharmacy.php to review our 2024 Pharmacy Drug (Formulary) Guide or call 800-537-9384.
                                                          • Drugs not on the formulary. Formularies are developed and reviewed by the CVS Caremark Pharmacy and Therapeutics Committee, comprised of physicians, pharmacists and other clinicians that review drugs for inclusion in the formulary. They consider the drug’s effectiveness and safety in their evaluation. The High Value formulary is a closed formulary, which means in order for your drug to be covered, it must be on our formulary. Drugs not on the High Value formulary will not be covered. If it is medically necessary for you to use a prescription drug not on the formulary, you or your prescriber must request a medical exception.Remember, a generic equivalent will be dispensed, if available, unless your physician specifically requires a brand name and writes "Dispense as Written" (DAW) on the prescription, so discuss this with your doctor.
                                                          • Choose generics. The Plan requires the use of generics if a generic drug is available. If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/ coinsurance* unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained from the Plan. Generics contain the same active ingredients in the same amounts as their brand name counterparts and have been approved by the FDA. By using generic drugs, you will see cost savings, without jeopardizing clinical outcome or compromising quality. * The differential/penalty will not apply to Plan accumulators (example: deductible and out-of-pocket maximum)
                                                          • Precertification. Your pharmacy benefits plan includes precertification. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-approved by our Pharmacy Management Precertification Unit before they will be covered. Only your physician or pharmacist, in the case of an antibiotic or analgesic, can request precertification for a drug. Step therapy is another type of precertification. Certain medications will be excluded from coverage unless you try one or more ”step” drug(s) first, or unless a medical exception is obtained. The drugs requiring precertification or step therapy are subject to change. Visit our website at www.aetnafeds.com for the most current information regarding the precertification and step therapy lists. Ask your physician if the drugs being prescribed for you require precertification or step therapy.
                                                          • These are the dispensing limitations. Prescription drugs prescribed by a licensed physician or dentist and obtained at a participating Plan retail pharmacy for up to 90-day supply or by mail order may be dispensed for up to a 90-day supply of medication (if authorized by your physician). In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name. In the event that a member is called to active military duty and requires coverage under their prescription plan benefits of an additional filing of their medication(s) prior to departure, their pharmacist will need to contact Aetna. Coverage of additional prescriptions will only be allowed if there are refills remaining on the member's current prescription or a new prescription has been issued by their physician. The member is responsible for the applicable cost sharing for the additional prescription.
                                                          • The Plan allows coverage of a medication refill when at least 80% of the previous prescription, according to the physician’s prescribed directions, has been utilized. For a 30-day supply of medication, this provision would allow a prescription refill to be covered 24 days after the last filling, thereby allowing a member to have an additional supply of their medication, in case of emergency.
                                                          • When you do have to file a claim. Send your itemized bill(s) to: Aetna, P.O. Box 52444, Phoenix, AZ 85072-2444.

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

                                                          • A generic equivalent may be dispensed if it is available, and where allowed by law.
                                                          • Specialty drugs. Specialty drugs are medications that treat complex, chronic diseases which includes select oral, injectable and infused medications. The first fill including all subsequent refills of these medications must be obtained through a network specialty pharmacy.

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

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

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

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

                                                            Note: Certain drugs to treat Gender dysphoria and infertility are considered specialty drugs. Please see Specialty drugs in this section.

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

                                                            $10 per covered preferred generic formulary drug; and

                                                            50% per covered preferred brand formulary drug.

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

                                                            $30 per covered preferred generic formulary drug; and

                                                            50% per covered preferred brand formulary drug.

                                                            Preventive Care Medications

                                                            Medications to promote better health as recommended by ACA.

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

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

                                                            • Aspirin
                                                            • Folic acid supplements
                                                            • Oral Fluoride
                                                            • Statins
                                                            • Breast Cancer Prevention drugs
                                                            • HIV PrEP
                                                            • Nicotine Replacement Medications (Limits apply)
                                                            • Bowel Prep Medications (Required with preventive Colonoscopy)

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

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

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

                                                            Nothing (no deductible)

                                                            Women's contraceptive drugs and devices

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

                                                            Note: If it is medically necessary for you to use a prescription drug on the Formulary Exclusions List, you or your prescriber must request a medical exception. Visit our website at
                                                            www.aetnafeds.com/pharmacy.php to review our 2024 Pharmacy Drug (Formulary) Guide or call 800-537-9384.

                                                            Nothing (no deductible)

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

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

                                                            50% per covered preferred brand formulary drug.

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

                                                            50% per covered preferred brand formulary drug.

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

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

                                                            $10 per covered preferred generic formulary drug; and

                                                            50% per covered preferred brand formulary drug.

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

                                                            $30 per covered preferred generic formulary drug; and

                                                            50% per covered preferred brand formulary drug.

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

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

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

                                                            $10 per covered preferred generic formulary drug; and

                                                            50% per covered preferred brand formulary drug.

                                                            Limited benefits:

                                                            • Drugs to treat erectile dysfunction are limited up to six (6) tablets per 30-day period. Contact the Plan at 800-537-9384 for dose limits.

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

                                                            $10 per covered preferred generic formulary drug; and

                                                            50% per covered preferred brand formulary drug.

                                                            • Drugsavailable without a prescription (i.e., an over-the-counter (OTC) drug) unless required by law.
                                                            • Drugsobtained at a non-Plan pharmacy except when related to out-of-area emergency care
                                                            • Vitamins,unless otherwise stated (including prescription vitamins), nutritional supplements, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition when administered under the direction of a Plan doctor (please see Durable Medical Equipment in Section 5(a) for more information on what the plan will cover).
                                                            • Medicalsuppliessuchas dressings and antiseptics
                                                            • Lost, stolen or damaged drugs
                                                            • Drugsfor cosmetic purposes
                                                            • Drugsto enhance athletic performance
                                                            • Nonprescription medications unless specifically indicated elsewhere
                                                            • Prophylacticdrugs including, but not limited to, anti­ malarials for travel
                                                            • Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
                                                            • Compounded thyroid hormone therapy

                                                            Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See Section 5(a)). OTC drugs will not be covered unless you have a prescription and that prescription is presented at the pharmacy and processed through our pharmacy claim system.

                                                            Section 5(g). Dental Benefits

                                                            Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

                                                            • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 coordinating benefits with other coverage.
                                                            • The deductible is $1,000 Self Only or $2,000 for Self Plus One or Self and Family enrollment for Saver Option each calendar year. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this section.
                                                            • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
                                                            • Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. We do not cover the dental procedure. See Section 5(c) for inpatient hospital benefits.
                                                            • You must use Participating providers in our network in order to receive benefits. We recommend that you select a PCP by calling Member Services at 800-537-9384.

                                                            Be sure to read Section 4, Your costs for covered services, for valuable information about how cost- sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

                                                            We have no other dental benefits.

                                                            Note: See Oral and maxillofacial surgery, section 5(b).

                                                            30% of our plan allowance

                                                            Section 5(h). Wellness and Other Special Features

                                                            Under the flexible benefits option, we determine the most effective way to provide services.

                                                            • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
                                                            • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
                                                            • By approving an alternative benefit, we do not guarantee you will get it in the future.
                                                            • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
                                                            • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
                                                            • Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

                                                            Aetna Member Website

                                                            Aetna Member website, our secure member self-service website, provides you with the tools and personalized information to help you manage your health. Click on Aetna Member website from www.aetnafeds.com to register and access a secure, personalized view of your Aetna benefits.

                                                            • Review PCP selections
                                                            • Print temporary ID cards
                                                            • Download details about a claim such as the amount paid and the member’s responsibility
                                                            • Contact member services at your convenience through secure messages
                                                            • Access cost and quality information through Aetna’s transparency tools
                                                            • View and update your Personal Health Record
                                                            • Find information about the member extras that come with your plan
                                                            • Access health information through Healthwise® Knowledgebase

                                                            Registration assistance is available toll free, Monday through Friday, from 7am to 9pm Eastern Time at 800-225-3375. Register today at www.aetnafeds.com.

                                                            Special features-continued on next page

                                                            24-Hour Nurse Line

                                                            Provides eligible members with phone access to registered nurses experienced in providing information on a variety of health topics. 24-Hour Nurse Line is available 24 hours a day, 7 days a week. You may call 24-Hour Nurse Line at 800-556-1555. We provide TDD service for the hearing and speech-impaired. We also offer foreign language translation for non-English speaking members. 24-Hour Nurse Line nurses cannot diagnose, prescribe medication or give medical advice.

                                                            Enhanced Maternity Program:

                                                            Learn about what to expect before and after delivery, early labor symptoms, newborn care and more. We can also help you make choices for a healthy pregnancy, lower your risk for early labor, cope with postpartum depression and stop smoking. We will ask you questions to help us know you better and support you best. Enroll early and receive a reward when you sign up by the 16th week of pregnancy. To enroll in the program, call toll-free 1-800-272-3531 between 8 am and 7 pm ET.

                                                            Reciprocity benefit

                                                            If you need to visit a participating primary care provider for a covered service, and you are 50 miles or more away from home you may visit a primary care provider from our plan’s approved network.

                                                            • Call 800-537-9384 for provider information and location
                                                            • Select a doctor from 3 primary care providers in that area
                                                            • The Plan will authorize you for one visit and any tests or X-rays ordered by that primary care provider
                                                            • You must coordinate all subsequent visits through your own participating primary care provider

                                                            Non-FEHB Benefits Available to Plan Members

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

                                                            Eyewear and exams

                                                            Discounts on designer frames, prescription lenses, lens options like scratch coating, tint and non-disposable contact lenses. Save on LASIK laser eye surgery and replacement contact lenses delivered to your door. Save on accessories like eyeglass chains, lens cases, cleaners, and nonprescription sunglasses. Visit many doctors in private practice. Plus, national chains like LensCrafters®, Target Optical® and Pearle Vision®.

                                                            Hearing aids and exams

                                                            Save on hearing exams, a large choice of leading brand hearing aids, batteries and free routine follow-up services. There are two ways for you to save at thousands of locations through Hearing Care Solutions or Amplifon Hearing Health Care.

                                                            Healthy lifestyle choices

                                                            Save on gym memberships, health coaching, fitness gear and nutrition products that support a healthy lifestyle. Get access to local and national discounts on brands you know. At-home weight-loss programs with tips and menus. Also save on wearable fitness devices, meditation, yoga, wellness programs and group fitness on demand.

                                                            Natural products and services

                                                            Ease your stress and tension and save on therapeutic massage, acupuncture or chiropractic care. Get advice from registered dietitians with nutrition services. Save on popular products from health and fitness vendors, like blood pressure monitors, pedometers and activity trackers, devices for pain relief and many other products. Save on teeth whitening, electronic toothbrushes, replacement brush heads and various oral health care kits.

                                                            Getting started is easy, just log in to your member website at Aetnafeds.com, once you’re an Aetna member.

                                                            DISCOUNT OFFERS ARE NOT INSURANCE. They are not benefits under your insurance plan. You get access to discounts off the regular charge on products and services offered by third party vendors and providers. Aetna makes no payment to the third parties--you are responsible for the full cost. Check any insurance plan benefits you have before using these discount offers, as those benefits may give you lower costs than these discounts.

                                                            Discount vendors and providers are not agents of Aetna and are solely responsible for the products and services they provide. Discount offers are not guaranteed and may be ended at any time. Aetna may get a fee when you buy these discounted products and services.

                                                            Hearing products and services are provided by Hearing Care Solutions and Amplifon Hearing Health Care.

                                                            Vision care providers are contracted through EyeMed Vision Care. LASIK surgery discounts are offered by the U.S. Laser Network and Qualsight. Natural products and services are offered through ChooseHealthy®, a program provided by ChooseHealthy, Inc. which is a subsidiary of American Specialty Health Incorporated (ASH). ChooseHealthy is a registered trademark of ASH and is used with permission.

                                                            Section 6. General Exclusions – Services, Drugs and Supplies We Do not Cover

                                                            The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 When you need prior Plan approval for certain services.

                                                            We do not cover the following:

                                                            • Care by non-Plan providers except for authorized referrals or emergencies (See Emergency services/accidents).
                                                            • Services, drugs, or supplies you receive while you are not enrolled in this Plan.
                                                            • Services, drugs, or supplies not medically necessary.
                                                            • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
                                                            • Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants).
                                                            • Procedures, services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
                                                            • Services, drugs, or supplies you receive from a provider or facility barr ed or precluded from th e FEHB Progra m or other Federal Programs.
                                                            • Services, drugs, or supplies you receive without charge while in active military service.
                                                            • Cost of data collection and record keeping for clinical trials that would not be required, but for the clinical trial.
                                                            • Items and services provided by clinical trial sponsor without charge.
                                                            • Care for conditions that state or local law requires to be treated in a public facility, including but not limited to, mental illness commitments.
                                                            • Court ordered services, or those required by court order as a condition of parole or probation, except when medically necessary.
                                                            • Educational services for treatment of behavioral disorders.
                                                            • Services provided by a family member or resident in the member’s home.
                                                            • Services or supplies we are prohibited from covering under the Federal law.

                                                            Section 7. Filing a Claim for Covered Services

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

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

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

                                                            Medical, hospital and prescription drug benefits

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

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

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

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

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

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

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

                                                            Deadline for filing your claim

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

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

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

                                                            If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

                                                            Notice Requirements

                                                            If you live in a county where at least 10 % of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

                                                            Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

                                                            Section 8. The Disputed Claims Process

                                                            You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call Aetna's Customer Service at the phone number found on your ID card, plan brochure or plan website: www.aetnafeds.com.

                                                            Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

                                                            To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Customer Service Department by writing Aetna, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512 or calling 800-537-9384.

                                                            Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

                                                            When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

                                                            Our reconsideration will not take in account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.

                                                            We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

                                                            Ask us in writing to reconsider our initial decision. You must:

                                                            a) Write to us within 6 months from the date of our decision; and

                                                            b) Send your request to us at: Aetna, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512; and

                                                            c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

                                                            d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

                                                            e) Include your email address, if you would like to receive our decision via email. Please note that by providing your email address, you may receive our decision more quickly.

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

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

                                                            a) Pay the claim or

                                                            b) Write to you and maintain our denial or

                                                            c) Ask you or your provider for more information

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

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

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

                                                            You must write to OPM within:

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

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

                                                            Send OPM the following information:

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

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

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

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

                                                            4

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

                                                            If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

                                                            OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

                                                            You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

                                                            Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-537-9384. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM's FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.

                                                            Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a family member is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant, or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.

                                                            Section 9. Coordinating Benefits with Medicare and Other Coverage

                                                            When you have other health coverage

                                                            You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. This is called “double coverage.”

                                                            When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.aetnafeds.com/NAIC.php.

                                                            When we are the primary payor, we pay the benefits described in this brochure.

                                                            When we are the secondary payor, the primary Plan will process the benefit for the expenses first, up to its plan limit. If the expense is covered in full by the primary plan, we will not pay anything. If the expense is not covered in full by the primary plan, we determine our allowance. If the primary Plan uses a preferred provider arrangement, we use the lesser of the primary plan’s negotiated fee, Aetna’s Reasonable and Customary (R&C) and billed charges. If the primary plan does not use a preferred provider arrangement, we use the lesser of Aetna's R&C and billed charges. If the primary plan uses a preferred provider arrangement and Aetna does not, the allowable amount is the lesser of the primary plan's negotiated rate, Aetna's R&C and billed charges. If both plans do not use a preferred provider arrangement, we use the lesser of Aetna's R&C and billed charges.

                                                            For example, we generally only make up the difference between the primary payor's benefit payment and 100% of our Plan allowance, subject to your applicable deductible, if any, and coinsurance or copayment amounts.

                                                            When Medicare is the primary payor and the provider accepts Medicare assignment, our allowance is the difference between Medicare's allowance and the amount paid by Medicare. We do not pay more than our allowance. You are still responsible for your copayment, deductible or coinsurance based on the amount left after Medicare payment.

                                                            TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

                                                            Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing offic e. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

                                                            Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

                                                            We do not cover services that:

                                                            • You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
                                                            • OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.
                                                            • Medicaid

                                                            When you have this Plan and Medicaid, we pay first.

                                                            Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

                                                            When other Government agencies are responsible for your care

                                                            We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

                                                            When others are responsible for injuries

                                                            Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

                                                            If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

                                                            We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

                                                            Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

                                                            We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

                                                            If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

                                                            This Plan always pays secondary to:

                                                            • Any medical payment, PIP or No-Fault coverage under any automobile policy available to you.
                                                            • Any plan or program which is required by law. You should review your automobile insurance policy to ensure that uncoordinated medical benefits have been chosen so that the automobile insurance policy is the primary payer.

                                                            Note: For Motor Vehicle Accidents, charges incurred due to injuries received in an accident involving any motor vehicle for which no-fault insurance is available are excluded from coverage, regardless of whether any such no-fault policy is designated as secondary to health coverage.

                                                            For a complete explanation on how the Plan is authorized to operate when others are responsible for your injuries please go to: www.aetnafeds.com.

                                                            When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

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

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

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

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

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

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

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

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

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

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

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

                                                            Clinical Trials

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

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

                                                            • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan. See Section 5(b).
                                                            • Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs. See Section 5(b).
                                                            • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. We do not cover these costs. See Section 5(b).

                                                            For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

                                                            The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

                                                            All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

                                                            When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

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

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

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

                                                            We do not waive any costs if the Original Medicare Plan is your primary payor.

                                                            Please review the following examples which illustrates your cost share if you are enrolled in Medicare Parts A and B.

                                                            Basic Option: EXAMPLE

                                                            Benefit Description: Deductible
                                                            Basic Option You pay without Medicare: $0
                                                            Basic Option You pay with Medicare Parts A and B (primary): $0

                                                            Benefit Description: Part B Premium Reimbursement Offered
                                                            Basic Option You pay without Medicare: NA
                                                            Basic Option You pay with Medicare Parts A and B (primary): No reimbursement

                                                            Benefit Description: Primary Care Physician
                                                            Basic Option You pay without Medicare: $25 per visit
                                                            Basic Option You pay with Medicare Parts A and B (primary): $25 per visit

                                                            Benefit Description: Specialist
                                                            Basic Option You pay without Medicare: $55 per visit
                                                            Basic Option You pay with Medicare Parts A and B (primary): $55 per visit

                                                            Benefit Description: Inpatient Hospital
                                                            Basic Option You pay without Medicare: 20% of plan allowance per admission
                                                            Basic Option You pay with Medicare Parts A and B (primary): 20% of plan allowance per admission

                                                            Benefit Description: Outpatient Hospital
                                                            Basic Option You pay without Medicare: $350 per visit
                                                            Basic Option You pay with Medicare Parts A and B (primary): $350 per visit

                                                            Benefit Description: Incentives offered
                                                            Basic Option You pay without Medicare: NA
                                                            Basic Option You pay with Medicare Parts A and B (primary): We offer no additional incentives when a member has Medicare Part B.

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

                                                            If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage Plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country.

                                                            To learn more about Medicare Advantage Plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

                                                            If you enroll in a Medicare Advantage Plan, the following options are available to you:

                                                            This Plan and our Medicare Advantage Plan: You may enroll in our Medicare Advantage Plan and also remain enrolled in our FEHB Plan. If you are an annuitant or former spouse with FEHBP coverage and are enrolled in Medicare Parts A and B, you may enroll in our Medicare Advantage Plan if one is available in your area. Please call us at 888-788-0390. We do not waive cost-sharing for your FEHB coverage.

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

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

                                                            When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. For more information, please call us at 800-832-2640. See Important Notice from Aetna about our Prescription Drug Coverage and Medicare on the first inside page of this brochure for information on Medicare Part D. Note: You cannot have two Part D plans at the same time. If you are currently enrolled in an individual Medicare Part D Plan and choose to auto enroll or later opt-in to the High or Basic options EGWP PDP (Aetna Medicare Rx offered by SilverScript), you will be disenrolled from your individual Medicare Part D Plan.

                                                            Employer Group Waiver Plan offered to Open Access High and Basic members with Medicare Primary:

                                                            We offer a Medicare Employer Group Waiver Plan (EGWP) Prescription Drug Plan (PDP) to Medicare-eligible annuitants and Medicare eligible family members covered under the Plan. The EGWP PDP is a Medicare Part D plan and is actuarially equal to or better than the Open Access high or basic prescription drug benefits, meaning you will generally pay less for prescription drugs. Covered drugs will be subject to the formulary approved by the Centers for Medicare and Medicaid Services.

                                                            If you are an annuitant or an annuitant’s family member who is enrolled in either Medicare Part A or B or Parts A and B, you will be automatically enrolled in the EGWP PDP on January 1, 2024 or later upon becoming Medicare-eligible. There is no need for you or your eligible dependent to take action to enroll. If you do not wish to enroll in the Aetna Medicare Prescription Drug Plan, you may “opt-out” of the enrollment by following the instructions mailed to you. You will have 21 days to contact us at the toll-free number ( 833-271-9775) to decline Part D coverage. Declining coverage or “opting out” will place you back into your FEHB prescription drug coverage. Additionally, participation in the PDP EGWP is voluntary, and members can continue to opt out at any time. If you opt out after the first of the month, it will be effective the first of the following month.

                                                            We will pay the Medicare premium for this Part D drug plan coverage except any additional premium imposed due to exceeding the income threshold as defined by the Social Security Administration such as Income-Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra amount that you pay in addition to your FEHB premium for your monthly Medicare Part D prescription drug plan premiums and your monthly Medicare Part B premiums. Social Security makes this determination based on your income. This additional premium is assessed only to those with higher incomes and is adjusted based on the income reported on your IRS tax return. You do not make any IRMAA payments to your FEHB plan. Refer to the Part D-IRMAA section of the Medicare website:
                                                            https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans, to see if you would be subject to this additional premium.

                                                            Please see Section 5(f) for additional details regarding the EGWP PDP. Below is a side by side comparison of the FEHB prescription drug coverage compared to the EGWP PDP plan that is offered through Aetna Medicare Rx offered by SilverScript for this Plan.