Preferred provider organization (PPO) medical plan
Certificate of coverage
Prepared for:
Policyholder: SAMPLE CO, INC.
Policyholder number: GP- SAMPLE
Plan name: SAMPLE, Booklet-certificate: XX
Group policy effective date: SAMPLE
Plan effective date: SAMPLE
Plan issue date: SAMPLE
Underwritten by Aetna Life Insurance Company
The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his
or her status as a victim of family violence and sexual assault.
AL HCOC 08 as amended by
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Assistive Technology
Persons using assistive technology may not be able to fully access the following information. For assistance,
please call 1-888-982-3862.
Smartphone or Tablet
To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from
your App Store.
Non-Discrimination
Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat
people differently based on their race, color, national origin, sex, age, or disability.
We provide free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call 1-888-
982-3862.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class
noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinat[email protected].
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of
Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201,
or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).
AL HCOC 08 as amended by
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Language Assistance
TTY: 711
To access language services at no cost to you, call 1-888-982-3862.
Para acceder a los servicios de idiomas sin costo, llame al 1-888-982-3862. (Spanish)
AL HCOC 08 as amended by
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
AL HCOC 08 as amended by
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
AL HCOC 08 as amended by
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
AL HCOC 08 as amended by
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Table of contents
Welcome ................................................................................................... 1
Coverage and exclusions........................................................................... 3
General plan exclusions ..........................................................................29
How your plan works ..............................................................................35
Complaints, claim decisions and appeal procedures.............................. 49
Eligibility, starting and stopping coverage ..............................................53
General provisions – other things you should know .............................. 58
Glossary...................................................................................................61
Schedule of benefits Issued with your certificate of coverage
AL HCOC 08 as amended by
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Welcome
At Aetna, your health goals lead the way, so we’re joining you to put them first. We believe that whatever you
decide to do for your health, you can do it with the right support. And no matter where you are on this personal
journey, it’s our job to enable you to feel the joy of achieving your best health.
Welcome to Aetna.
Introduction
This is your certificate of coverage or “certificate.” It describes your covered services – what they are and how
to get them. The schedule of benefits tells you how we share expenses for covered services and explains any
limits. Along with the group policy, they describe your Aetna plan. Each may have amendments attached to
them. These change or add to the document. This certificate takes the place of any others sent to you before.
It’s really important that you read the entire certificate and your schedule of benefits.
If your coverage under any part of this plan replaces coverage under another plan, your coverage for benefits
provided under the other coverage may reduce benefits paid by this plan. See the General coverage provisions
section of the schedule of benefits.
If you need help or information, see the Contact us section below.
How we use words
When we use:
• “You” and “your” we mean you and any covered dependents (if your plan allows dependent coverage)
• “Us,” “we,” and “our” we mean Aetna
• Words that are in bold, we define them in the Glossary section
Contact us
For questions about your plan, you can contact us by:
• Calling the toll-free number on your ID card
• Logging in to the Aetna website at https://www.aetna.com/
• Writing us at 151 Farmington Ave, Hartford, CT 06156
Your member website is available 24/7. With your member website, you can:
• See your coverage, benefits and costs
• Print an ID card and various forms
• Find a provider, research providers, care and treatment options
• View and manage claims
• Find information on health and wellness
Your ID card
Show your ID card each time you get covered services from a provider. Only members on your plan can use your
ID card. We will mail you your ID card. If you haven’t received it before you need covered services, or if you lose
it, you can print a temporary one using the Aetna website.
AL HCOC 08 as amended by 1
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Wellness and other rewards
You may be eligible to earn rewards for completing certain activities that improve your health, coverage, and
experience with us. We may encourage you to access certain health services, or categories of healthcare
providers, participate in programs, including but not limited to financial wellness programs; utilize tools,
improve your health metrics or continue participation as an Aetna member through incentives. Talk with your
provider about these and see if they are right for you. We may provide incentives based on your participation
and outcomes such as:
• Modifications to copayment, deductible or coinsurance amounts
• Contributions to your health savings account
• Merchandise
• Coupons
• Gift or debit cards
• Any combination of the above
Discount arrangements
We can offer you discounts on health care related goods or services. Sometimes, other companies provide these
discounted goods and services. These companies are called “third-party service providers”. These third-party
service providers may pay us so that they can offer you their services.
Third-party service providers are independent contractors. The third-party service provider is responsible for the
goods and services they deliver. We have the right to change or end the arrangements at any time.
These discount arrangements are not insurance. We don’t pay the third-party service providers for the services
they offer. You are responsible for paying for their services and discounted goods.
AL HCOC 08 as amended by 2
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Coverage and exclusions
Providing cover ed services
Your plan provides covered services. These are:
• Described in this section.
• Not listed as an exclusion in this section or the General plan exclusions section.
• Not beyond any limits in the schedule of benefits.
• Medically necessary. See the How your plan works – Medical necessity and precertification requirements
section and the Glossary for more information.
For covered services under the outpatient prescription drug plan:
• You need a prescription from the prescribing provider
• You need to show your ID card to the network pharmacy when you get a prescription filled
This plan provides insurance coverage for many kinds of covered services, such as a doctor’s care and hospital
stays, but some services aren’t covered at all or are limited. For other services, the plan pays more of the
expense. For example:
• Physician care generally is covered but physician care for cosmetic surgery is never covered. This is an
exclusion.
• Home health care is generally covered but it is a covered service only up to a set number of visits a year.
This is a limitation.
• Your provider may recommend services that are considered experimental or investigational services.
But an experimental or investigational service is not covered and is also an exclusion, unless it is
recognized as part of an approved clinical trial when you have cancer or a terminal illness. See Clinical
trials in the list of services below.
• Preventive services. Usually the plan pays more, and you pay less. Preventive services are designed to
help keep you healthy, supporting you in achieving your best health. To find out what these services are,
see the Preventive care section in the list of services below. To find out how much you will pay for these
services, see Preventive care in your schedule of benefits.
Some services require precertification from us. For more information see the How your plan works – Medical
necessity and precertification requirements section.
The covered services and exclusions below appear alphabetically to make it easier to find what you’re looking
for. You can find out about limitations for covered services in the schedule of benefits. If you have questions,
contact us.
Acupuncture
Covered services include manual or electro acupuncture.
The following are not covered services:
• Acupressure
AL HCOC 08 as amended by 3
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Ambulance services
An ambulance is a vehicle staffed by medical personnel and equipped to transport an ill or injured person.
Emergency
Covered services include emergency transport to a hospital by a licensed ambulance:
• To the first hospital to provide emergency services
• From one hospital to another if the first hospital can’t provide the emergency services you need
• When your condition is unstable and requires medical supervision and rapid transport
Non-emergency
Covered services also include precertified transportation to a hospital by a licensed ambulance:
• From a hospital to your home or to another facility if an ambulance is the only safe way to transport you
• From your home to a hospital if an ambulance is the only safe way to transport you; limited to 100 miles
• When during a covered inpatient stay at a hospital, skilled nursing facility or acute rehabilitation
hospital, an ambulance is required to safely and adequately transport you to or from inpatient or
outpatient treatment
The following are not covered services:
• Ambulance services for routine transportation to receive outpatient or inpatient services
Applied behavior analysis
Covered services include applied behavior analysis for a diagnosis of autism spectrum disorder. Applied
behavior analysis is a process of applying interventions that:
• Systematically change behavior
• Are responsible for observable improvements in behavior
Autism spectrum disorder
Autism spectrum disorder is defined in the most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) of the American Psychiatric Association.
Covered services include services and supplies provided by a physician or behavioral health provider for:
• The diagnosis and treatment of autism spectrum disorder
• Physical, occupational, and speech therapy associated with the diagnosis of autism spectrum disorder
Behavioral health
Mental health treatment
Covered services include the treatment of mental health disorders provided by a hospital, psychiatric hospital,
residential treatment facility, physician, or behavioral health provider including:
• Inpatient room and board at the semi-private room rate (your plan will cover the extra expense of a
private room when appropriate because of your medical condition), and other services and supplies
related to your condition that are provided during your stay in a hospital, psychiatric hospital, or
residential treatment facility
AL HCOC 08 as amended by 4
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or
residential treatment facility, including:
‒ Office visits to a physician or behavioral health provider such as a psychiatrist, psychologist, social
worker, or licensed professional counselor (includes telemedicine consultation)
‒ Individual, group, and family therapies for the treatment of mental health disorders
‒ Other outpatient mental health treatment such as:
o Partial hospitalization treatment provided in a facility or program for mental health treatment
provided under the direction of a physician
o Intensive outpatient program provided in a facility or program for mental health treatment
provided under the direction of a physician
o Skilled behavioral health services provided in the home, but only when all of the following
criteria are met:
▪ You are homebound
▪ 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
o
Electro-convulsive therapy (ECT)
o Transcranial magnetic stimulation (TMS)
o Psychological testing
o Neuropsychological testing
o Observation
o Peer counseling support by a peer support specialist (including telemedicine consultation)
Substance related disorders treatment
Covered services include the treatment of substance related disorders provided by a hospital, psychiatric
hospital, residential treatment facility, physician, or behavioral health provider as follows:
• Inpatient room and board, at the semi-private room rate (your plan will cover the extra expense of a
private room when appropriate because of your medical condition), and other services and supplies that
are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility.
• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or
residential treatment facility, including:
- Office visits to a physician or behavioral health provider such as a psychologist, social worker, or
licensed professional counselor (includes telemedicine consultation)
- Individual, group, and family therapies for the treatment of substance related disorders
- Other outpatient substance related disorders treatment such as:
o
Partial hospitalization treatment provided in a facility or program for treatment of substance
related disorders provided under the direction of a physician
o Intensive outpatient program provided in a facility or program for treatment of substance
related disorders provided under the direction of a physician
o Skilled behavioral health services provided in the home, but only when all of the following
criteria are met:
▪ You are homebound
▪ Your physician orders them
AL HCOC 08 as amended by 5
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
▪ 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
o Ambulatory or outpatient detoxification which includes outpatient services that monitor
withdrawal from alcohol or other substances, including administration of medications
o Observation
o Peer counseling support by a peer support specialist (including telemedicine consultation)
Behavioral health important note:
A peer support specialist serves as a role model, mentor, coach, and advocate. Peer support must be supervised
by a behavioral health provider.
Clinical trials
Routine patient costs
Covered services include routine patient costs you have from a provider in connection with participation in an
approved clinical trial as defined in the federal Public Health Service Act, Section 2709.
The following are not covered services:
• Services and supplies related to data collection and record-keeping needed only for the clinical trial
• Services and supplies provided by the trial sponsor for free
• The experimental intervention itself (except Category B investigational devices and promising
experimental or investigational interventions for terminal illnesses in certain clinical trials in
accordance with our policies)
Experimental or i nvestigational therapies
Covered services include drugs, devices, treatments, or procedures from a provider under an “approved clinical
trial” only when you have cancer or a terminal illness. All of the following conditions must be met:
• Standard therapies have not been effective or are not appropriate
• We determine you may benefit from the treatment
An approved clinical trial is one that meets all of these requirements:
• The Food and Drug Administration (FDA) has approved the drug, device, treatment, or procedure to be
investigated or has granted it investigational new drug (IND) or group c/treatment IND status, when this
is required
• The clinical trial has been approved by an institutional review board that will oversee it
• The clinical trial is sponsored by the National Cancer Institute (NCI) or similar federal organization and:
- It conforms to standards of the NCI or other applicable federal organization
- It takes place at an NCI-designated cancer center or at more than one institution
• You are treated in accordance with the procedures of that study
Dental care anesthesia
Covered services include anesthesia and facility costs for dental care. Your doctor must certify that the dental
care cannot be performed in the dentist’s office due either to age or medical condition.
The following are not covered services:
• The related dental service unless specifically listed as a covered service in this certificate
AL HCOC 08 as amended by 6
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Diabetic services, supplies, equipment, and self-care programs
Covered services include:
• Services
- Foot care to minimize the risk of infection
• Supplies
- Injection devices including syringes, needles and pens
- Test strips - blood glucose, ketone and urine
- Blood glucose calibration liquid
- Lancet devices and kits
- Alcohol swabs
• Equipment
- External insulin pumps and pump supplies
- Blood glucose monitors without special features, unless required due to blindness
• Prescribed self-care programs with a health care provider certified in diabetes self-care training
Durable medical equipment (DME)
DME and the accessories needed to operate it are:
• Made to withstand prolonged use
• Mainly used in the treatment of illness or injury
• Suited for use in the home
• Not normally used by people who do not have an illness or injury
• Not for altering air quality or temperature
• Not for exercise or training
Your plan only covers the same type of DME that Medicare covers but, there are some DME items Medicare
covers that your plan does not.
Covered services include the expense of renting or buying DME and accessories you need to operate the item
from a DME supplier. If you purchase DME, that purchase is only covered if you need it for long-term use.
Covered services also include:
• One item of DME for the same or similar purpose
• Repairing DME due to normal wear and tear
• A new DME item you need because your physical condition has changed
• Buying a new DME item to replace one that was damaged due to normal wear, if it would be cheaper
than repairing it or renting a similar item
The following are not covered services:
• Communication aid
• Elevator
• Maintenance and repairs that result from misuse or abuse
• Massage table
• Message device (personal voice recorder)
• Over bed table
• Portable whirlpool pump
• Sauna bath
• Telephone alert system
AL HCOC 08 as amended by 7
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
• Vision aid
• Whirlpool
Emergency services
When you experience an emergency medical condition, you should go to the nearest emergency room. You can
also dial 911 or your local emergency response service for medical and ambulance help.
Covered services include only outpatient services to evaluate and stabilize an emergency medical condition in a
hospital emergency room. You can get emergency services from network providers or out-of-network
providers.
Your coverage for emergency services will continue until the following conditions are met:
• You are evaluated and your condition is stabilized
• Your attending physician determines that you are medically able to travel or be transported, by non-
medical or non-emergency transportation, to another provider if you need more care
If your physician decides you need to stay in the hospital (emergency admission) or receive follow-up care,
these are not emergency services. Different benefits and requirements apply. Please refer to the How your plan
works – Medical necessity and precertification requirements section and the Coverage and exclusions section
that fits your situation (for example, Hospital care or Physician services). You can also contact us or your
network physician or primary care physician (PCP).
Non-emergency services
If you go to an emergency room for what is not an emergency medical condition, the plan may not cover your
expenses. See the schedule of benefits for this information.
The following are not covered services:
• Non-emergency care in a hospital emergency room
Gender affirming t reatment
Covered services include certain services and supplies for gender affirming (sometimes called sex change)
treatment.
Important note:
Visit https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html for
detailed information about this benefit, including eligibility and medical necessity requirements.
You can also call the toll-free number on your ID card.
Habilitation therapy services
Habilitation therapy services help you keep, learn or improve skills and functioning for daily living (e.g. therapy
for a child who isn’t walking or talking at the expected age). The services must follow a specific treatment plan,
ordered by your physician. The services must be performed by a:
• Licensed or certified physical, occupational or speech therapist
• Hospital, skilled nursing facility or hospice facility
• Home health care agency
• Physician
AL HCOC 08 as amended by 8
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
AL HCOC 08 as amended by 9
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Outpatient physical, occupational, and speech therapy
Covered services include:
• Physical therapy if it is expected to develop any impaired function
• Occupational therapy if it is expected to develop any impaired function
• Speech therapy if it is expected to develop speech function that resulted from delayed development
(speech function is the ability to express thoughts, speak words and form sentences)
The following are not covered services:
• Services provided in an educational or training setting or to teach sign language
• Vocational rehabilitation or employment counseling
Hearing aids
Hearing aid means:
• Any wearable, non-disposable instrument or device designed to aid or make up for impaired hearing
• Parts, attachments or accessories
Covered services include prescribed hearing aids and the following hearing aid services:
• Audiometric hearing visit and evaluation for a hearing aid prescription performed by:
- A physician certified as an otolaryngologist or otologist
- An audiologist who:
o Is legally qualified in audiology
o Holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing
Association in the absence of any licensing requirements
o Performs the exam at the written direction of a legally qualified otolaryngologist or otologist
• Electronic hearing aids, installed in accordance with a prescription written during a covered hearing
exam
• Any other related services necessary to access, select, and adjust or fit a hearing aid
The following are not covered services:
• Replacement of:
- A hearing aid that is lost, stolen or broken
- A hearing aid installed within a 48 month period
• Batteries or cords
• A hearing aid that does not meet the specifications prescribed for correction of hearing loss
Hearing ex ams
Covered services include hearing exams for evaluation and treatment of illness, injury or hearing loss when
performed by a hearing specialist.
The following are not covered services:
• Hearing exams given during a stay in a hospital or other facility, except those provided to newborns as
part of the overall hospital stay
Home health care
Covered services include home health care provided by a home health care agency in the home, but only when
all of the following criteria are met:
• You are homebound
• Your physician orders them
• The services take the place of a stay in a hospital or a skilled nursing facility, or you are unable to
receive the same services outside your home
• The services are a part of a home health care plan
• The services are skilled nursing services, home health aide services or medical social services, or are
short-term speech, physical or occupational therapy
• Home health aide services are provided under the supervision of a registered nurse
• Medical social services are provided by or supervised by a physician or social worker
If you are discharged from a hospital or skilled nursing facility after a stay, the intermittent requirement may be
waived to allow coverage for continuous skilled nursing services. See the schedule of benefits for more
information on the intermittent requirement.
Short-term physical, speech, and occupational therapy provided in the home are subject to the same conditions
and limitations imposed on therapy provided outside the home. See Rehabilitation services and Habilitation
therapy services in this section and the schedule of benefits.
The following are not covered services:
• Custodial care
• Services provided outside of the home (such as in conjunction with school, vacation, work, or
recreational activities)
• Transportation
• Services or supplies provided to a minor or dependent adult when a family member or caregiver is not
present
Hospice care
Covered services include inpatient and outpatient hospice care when given as part of a hospice care program.
The types of hospice care services that are eligible for coverage include:
• Room and board
• Services and supplies furnished to you on an inpatient or outpatient basis
• Services by a hospice care agency or hospice care provided in a hospital
• Psychological and dietary counseling
• Pain management and symptom control
• Bereavement counseling
• Respite care
Hospice care services provided by the providers below will be covered, even if the providers are not an
employee of the hospice care agency responsible for your care:
• A physician for consultation or case management
• A physical or occupational therapist
• A home health care agency for:
- Physical and occupational therapy
- Medical supplies
- Outpatient prescription drugs
- Psychological counseling
- Dietary counseling
AL HCOC 08 as amended by 10
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
The following are not covered services:
• Funeral arrangements
• Pastoral counseling
• Financial or legal counseling including estate planning and the drafting of a will
• Homemaker services, caretaker services, or any other services not solely related to your care, which may
include:
- Sitter or companion services for you or other family members
- Transportation
- Maintenance of the house
Hospital care
Covered services include inpatient and outpatient hospital care. This includes:
• Semi-private room and board. Your plan will cover the extra expense of a private room when
appropriate because of your medical condition.
• Services and supplies provided by the outpatient department of a hospital, including the facility charge.
• Services of physicians employed by the hospital.
• Administration of blood and blood derivatives, but not the expense of the blood or blood product.
The following are not covered services:
• All services and supplies provided in:
- Rest homes
- Any place considered a person’s main residence or providing mainly custodial or rest care
- Health resorts
- Spas
- Schools or camps
Infertility services
Basic infertility
Covered services include seeing a provider:
• To diagnose and evaluate the underlying medical cause of infertility.
• To do surgery to treat the underlying medical cause of infertility. Examples are endometriosis surgery
or, for men, varicocele surgery.
The following are not covered services:
• All infertility services associated with or in support of an ovulation induction cycle while on injectable
medication to stimulate the ovaries. This includes, but is not limited to, imaging, laboratory services, and
professional services.
• Artificial insemination services.
Jaw joint d isorder treatment
Covered services include the diagnosis, surgical and non-surgical treatment of jaw joint disorder by a provider,
including:
• The jaw joint itself, such as temporomandibular joint dysfunction (TMJ) syndrome
• The relationship between the jaw joint and related muscle and nerves, such as myofascial pain
dysfunction (MPD)
AL HCOC 08 as amended by 11
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Maternity and related newborn care
Covered services include pregnancy (prenatal) care, care after delivery and obstetrical services. After your child
is born, covered services include:
• No less than 48 hours of inpatient care in a hospital after a vaginal delivery
• No less than 96 hours of inpatient care in a hospital after a cesarean delivery
• A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or
newborn earlier
If the mother is discharged earlier, the plan will pay for 2 home visits after delivery by a health care provider.
Covered services also include services and supplies needed for circumcision by a provider.
The following are not covered services:
• Any services and supplies related to births that take place in the home or in any other place not licensed
to perform deliveries
Oral and maxillofacial treatment (mouth, jaws and teeth)
Covered services include the following when provided by a physician, dentist and hospital:
• Cutting out:
− Teeth partly or completely impacted in the bone of the jaw
− Teeth that will not erupt through the gum
− Other teeth that cannot be removed without cutting into bone
− The roots of a tooth without removing the entire tooth
− Cysts, tumors, or other diseased tissues
• Cutting into gums and tissues of the mouth:
− Only when not associated with the removal, replacement or repair of teeth
Also, the exclusions for this benefit have moved to the General exclusions section.
Outpatient surgery
Covered services include services provided and supplies used in connection with outpatient surgery performed
in a surgery center or a hospital’s outpatient department.
Important note:
Some surgeries can be done safely in a physician’s office. For those surgeries, your plan will pay only for
physician, PCP services and not for a separate fee for facilities.
The following are not covered services:
• A stay in a hospital (see Hospital care in this section)
• A separate facility charge for surgery performed in a physician’s office
• Services of another physician for the administration of a local anesthetic
Physician services
Covered services include services by your physician to treat an illness or injury. You can get services:
• At the physician’s office
• In your home
• In a hospital
AL HCOC 08 as amended by 12
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
• From any other inpatient or outpatient facility
• By way of telemedicine
Important note:
For behavioral health services, all in-person, covered services with a behavioral health provider are also
covered services if you use telemedicine instead.
Other services and supplies that your physician may provide:
• Allergy testing and allergy injections
• Radiological supplies, services, and tests
• Immunizations that are not covered as preventive care
Physician surgical services
Covered services include the services of:
• The surgeon who performs your surgery
• Your surgeon who you visit before and after the surgery
• Another surgeon who you go to for a second opinion before the surgery
The following are not covered services:
• A stay in a hospital (See Hospital care in this section)
• A separate facility charge for surgery performed in a physician’s office
• Services of another physician for the administration of a local anesthetic
Prescription drugs - outpatient
Read this section carefully. This plan does not cover all prescription drugs and some coverage may be limited.
This doesn’t mean you can’t get prescription drugs that aren’t covered; you can, but you have to pay for them
yourself. For more information about prescription drug benefits, including limits, see the schedule of benefits.
Important note:
A pharmacy may refuse to fill or refill a prescription when, in the professional judgement of the pharmacist,
it should not be filled or refilled.
Your plan provides standard safety checks to encourage safe and appropriate use of medications. These checks
are intended to avoid adverse events and align with the medication’s FDA-approved prescribing information and
current published clinical guidelines and treatment standards. These checks are routinely updated as new
medications come to market and as guidelines and standards are updated.
Covered services are based on the drugs in the drug guide. We exclude prescription drugs listed on the
formulary exclusions list unless we approve a medical exception. If it is medically necessary for you to use a
prescription drug that is not on this drug guide, you or your provider must request a medical exception. See the
Precertification section or just contact us.
Your provider can give you a prescription in different ways including:
• A written prescription that you take to a network pharmacy
• Calling or e-mailing a prescription to a network pharmacy
• Submitting the prescription to a network pharmacy electronically
AL HCOC 08 as amended by 13
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Prescription drug synchronization
If you are prescribed multiple maintenance medications and would like to have them each dispensed on the
same fill date for your convenience, your network pharmacy may be able to coordinate that for you. This is
called synchronization. We will apply a prorated daily cost share rate, to a partial fill of a maintenance drug, if
needed, to synchronize your prescription drugs.
How to access network pharmacies
A network pharmacy will submit your claim. You will pay your cost share to the pharmacy. You can find a
network pharmacy either online or by phone. See the Contact us section for how.
You may go to any of our network pharmacies.
Some prescription drugs are subject to quantity limits. This helps your provider and pharmacy ensure your
prescription drug is being used correctly and safely. We rely on medical guidelines, FDA-approved
recommendations and other criteria developed by us to set these limits.
Any prescription drug made to work beyond one month shall require the copayment amount that equals the
expected duration of the medication.
The pharmacy may substitute a generic prescription drug for a brand-name prescription drug. Your cost share
may be less if you use a generic drug when it is available.
Pharmacy types
Retail pharmacy
A retail pharmacy may be used for up to a 90 day supply of a prescription drug.
Mail order pharmacy
The drugs available through mail order are maintenance drugs that you take on a regular basis for a chronic or
long-term medical condition. A mail order pharmacy may be used for up to a 90 day supply of a prescription
drug.
Prescription refills after the initial fill can be filled at a network mail order pharmacy.
AL HCOC 08 as amended by 14
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Specialty pharmacy
A specialty pharmacy may be used for up to a 30 day supply of a specialty prescription drug. You can view the
list of specialty prescription drugs. See the Contact us section for how.
All specialty prescription drug fills after the first fill must be filled at a specialty pharmacy unless it is an urgent
situation.
Prescription drugs covered by this plan are subject to misuse, waste, or abuse utilization review by us, your
provider, and/or your network pharmacy. The outcome of this review may include:
• Limiting coverage of a drug to one prescribing provider or one network pharmacy
• Quantity, dosage or day supply limits
• Requiring a partial fill or denial of coverage
How to access out-of-network pharmacies
You can directly access an out-of-network pharmacy to get covered outpatient prescription drugs.
When you use an out-of-network pharmacy, you pay your in-network copayment or coinsurance then you pay
any remaining deductible and then you pay your out-of-network coinsurance. If you use an out-of-network
pharmacy to obtain outpatient prescription drugs, you are subject to a higher out-of-pocket expense and are
responsible for:
• Paying your in-network outpatient prescription drug cost share
• Paying your out-of-network outpatient prescription drug deductible
• Your out-of-network coinsurance
• Any charges over the allowable amount
• Submitting your own claims
Other covered services
Anti-cancer drugs taken by mouth, including chemotherapy drugs
Covered services include any drug prescribed for cancer treatment. The drug must be recognized for treating
cancer in standard reference materials or medical literature even if it isn’t approved by the FDA for this
treatment.
Contraceptives (birth control)
For females who are able to become pregnant, covered services include certain drugs and devices that the FDA
has approved to prevent pregnancy. You will need a prescription from your provider and must fill it at a
network pharmacy. At least one form of each FDA-approved contraception method is a covered service. You can
access a list of covered drugs and devices. See the Contact us section for how.
We also cover over-the-counter (OTC) and generic prescription drugs and devices for each method of birth
control approved by the FDA at no cost to you. If a generic drug or device is not available for a certain method,
we will cover the brand-name prescription drug or device at no cost share.
Preventive contraceptives important note:
You may qualify for a medical exception if your provider determines that the contraceptives covered as
preventive covered services under the plan are not medically appropriate for you. Your provider may
request a medical exception and submit it to us for review. If the exception is approved, the brand-name
prescription drug contraceptive will be covered at 100%.
AL HCOC 08 as amended by 15
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Diabetic supplies
Covered services include but are not limited to the following:
• Alcohol swabs
• Blood glucose calibration liquid
• Diabetic syringes, needles and pens
• Continuous glucose monitors
• Insulin infusion disposable pumps
• Lancet devices and kits
• Test strips for blood glucose, ketones, urine
See the Diabetic services, supplies, equipment, and self-care programs section for medical covered services.
Immunizations
Covered services include preventive immunizations as required by the ACA when given by a network pharmacy.
You can find a participating network pharmacy by contacting us. Check with the pharmacy before you go to
make sure the vaccine you need is in stock. Not all pharmacies carry all vaccines.
Infertility drugs
Covered services include synthetic ovulation stimulant prescription drugs used to treat the underlying medical
cause of infertility.
OTC drugs
Covered services include certain OTC medications when you have a prescription from your provider. You can
see a list of covered OTC drugs by logging on to the Aetna website.
Preventive care drugs and supplements
Covered services include preventive care drugs and supplements, including OTC ones, as required by the ACA.
Risk reducing breast cancer prescription drugs
Covered services include prescription drugs used to treat people who are at:
• Increased risk for breast cancer
• Low risk for medication side effects
Tobacco cessation prescription and OTC drugs
Covered services include FDA approved prescription and OTC drugs to help stop the use of tobacco products.
You must receive a prescription from your provider and submit the prescription to the pharmacy for processing.
The following are not covered services:
• Abortion drugs
• Allergy sera and extracts given by injection
• Any services related to providing, injecting or application of a drug
• Compounded prescriptions containing bulk chemicals not approved by the FDA including compounded
bioidentical hormones
• Cosmetic drugs including medication and preparations used for cosmetic purposes
• Devices, products and appliances unless listed as a covered service
• Dietary supplements including medical foods
• Drugs or medications
AL HCOC 08 as amended by 16
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
- Administered or entirely consumed at the time and place it is prescribed or provided
- Which do not require a prescription by law, even if a prescription is written, unless we have
approved a medical exception
- That is therapeutically the same or an alternative to a covered prescription drug, unless we approve
a medical exception
- Not approved by the FDA or not proven safe or effective
- Provided under your medical plan while inpatient at a healthcare facility
- Recently approved by the FDA but not reviewed by our Pharmacy and Therapeutics Committee,
unless we have approved a medical exception
- That include vitamins and minerals unless recommended by the United States Preventive Services
Task Force (USPSTF)
- That are used to treat sexual dysfunction, enhance sexual performance or increase sexual desire,
including drugs, implants, devices or preparations to correct or enhance erectile function, enhance
sensitivity or alter the shape or appearance of a sex organ unless listed as a covered service
- That are used for the purpose of weight gain or loss including but not limited to stimulants,
preparations, foods or diet supplements, dietary regimens and supplements, food or food
supplements, appetite suppressants or other medications
- That are drugs or growth hormones used to stimulate growth and treat idiopathic short stature
unless there is evidence that the member meets one or more clinical criteria detailed in our
precertification and clinical policies
• Duplicative drug therapy; for example, two antihistamines for the same condition
• Genetic care including:
- Any treatment, device, drug, service or supply to alter the body’s genes, genetic makeup or the
expression of the body’s genes
• Immunizations related to travel or work
• Immunization or immunological agents except as specifically stated in the schedule of benefits or the
certificate
• Implantable drugs and associated devices except as specifically stated in the schedule of benefits or the
certificate
• Infertility:
- Injectable prescription drugs used primarily for the treatment of infertility
• Injectables including:
- Any charges for the administration or injection of prescription drugs
- Needles and syringes except for those used for insulin administration
- Any drug which, due to its characteristics as determined by us, must typically be administered or
supervised by a qualified provider or licensed certified health professional in an outpatient setting
with the exception of Depo Provera and other injectable drugs for contraception
• Off-label drug use except for indications recognized through peer-reviewed medical literature
• Prescription drugs:
- That are ordered by a dentist or prescribed by an oral surgeon in relation to the removal of teeth or
prescription drugs for the treatment to a dental condition
- That are considered oral dental preparations and fluoride rinses except pediatric fluoride tablets or
drops as specified on the plan’s drug guide
- That are being used or abused in a manner that is determined to be furthering an addiction to a
habit-forming substance, or drugs obtained for use by anyone other than the member as identified
on the ID card
AL HCOC 08 as amended by 17
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
• Replacement of lost or stolen prescriptions
• Test agents except diabetic test agents
• Tobacco cessation drugs, unless recommended by the USPSTF
• We reserve the right to exclude:
- A manufacturer’s product when the same or similar drug (one with the same active ingredient or
same therapeutic effect), supply or equipment is on the plan’s drug guide
- Any dosage or form of a drug when the same drug is available in a different dosage or form on the
plan’s drug guide
Preventive care
Preventive covered services are designed to help keep you healthy, supporting you in achieving your best health
through early detection. If you need further services or testing such as diagnostic testing, you may pay more as
these services aren’t preventive. If a covered service isn’t listed here under preventive care, it still may be
covered under other covered services in this section. For more information, see your schedule of benefits.
The following agencies set forth the preventive care guidelines in this section:
• Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC)
• United States Preventive Services Task Force (USPSTF)
• Health Resources and Services Administration
• American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration
guidelines for children and adolescents
These recommendations and guidelines may be updated periodically. When updated, they will apply to this
plan. The updates are effective on the first day of the year, one year after the updated recommendation or
guideline is issued.
For frequencies and limits, contact your physician or us. This information is also available at
https://www.healthcare.gov/.
Important note:
Gender-specific preventive care benefits include covered services described regardless of the sex you were
assigned at birth, your gender identity, or your recorded gender.
AL HCOC 08 as amended by 18
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Breast-feeding support and counseling services
Covered services include assistance and training in breast-feeding and counseling services during pregnancy or
after delivery. Your plan will cover this counseling only when you get it from a certified breast-feeding support
provider.
Breast pump, accessories and supplies
Covered services include renting or buying equipment you need to pump and store breast milk.
Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or
similar purpose, and the accessories and supplies needed to operate the item. You are responsible for the entire
cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or
mobility.
Counseling services
Covered services include preventive screening and counseling by your health professional for:
• Alcohol or drug misuse
- Preventive counseling and risk factor reduction intervention
- Structured assessment
• Genetic risk for breast and ovarian cancer
• Obesity and healthy diet
- Preventive counseling and risk factor reduction intervention
- Nutritional counseling
- Healthy diet counseling provided in connection with hyperlipidemia (high cholesterol) and other
known risk factors for cardiovascular and diet-related chronic disease
• Sexually transmitted infection
• Tobacco cessation
- Preventive counseling to help stop using tobacco products
- Treatment visits
- Class visits
Family planning services – female contraceptives
Covered services include family planning services as follows:
• Counseling services provided by a provider on contraceptive methods. These will be covered when you
get them in either a group or individual setting.
• Contraceptive devices (including any related services or supplies) when they are prescribed, provided,
administered, or removed by a health professional.
• Voluntary sterilization including charges billed separately by the provider for female voluntary
sterilization procedures and related services and supplies. This also could include tubal ligation and
sterilization implants.
The following are not preventive covered services:
• Services provided as a result of complications resulting from a voluntary sterilization procedure and
related follow-up care
• Any contraceptive methods that are only “reviewed” by the FDA and not “approved” by the FDA
• Male contraceptive methods, sterilization procedures or devices, except for male condoms prescribed
by a health professional
AL HCOC 08 as amended by 19
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Immunizations
Covered services include preventive immunizations for infectious diseases.
The following are not preventive covered services:
• Immunizations that are not considered preventive care, such as those required due to your employment
or travel
Prenatal care
Covered services include your routine pregnancy physical exams at the physician, PCP, OB, GYN or OB/GYN
office. The exams include initial and subsequent visits for:
• Anemia screening
• Blood pressure
• Chlamydia infection screening
• Fetal heart rate check
• Fundal height
• Gestational diabetes screening
• Gonorrhea screening
• Hepatitis B screening
• Maternal weight
• Rh incompatibility screening
Routine cancer screenings
Covered services include the following routine cancer screenings:
• Colonoscopies including pre-procedure specialist consultation, removal of polyps during a screening
procedure, and a pathology exam on any removed polyp
• Digital rectal exams (DRE)
• Double contrast barium enemas (DCBE)
• Fecal occult blood tests (FOBT)
• Lung cancer screenings
• Mammograms
• Prostate specific antigen (PSA) tests
• Sigmoidoscopies
Routine physical exams
A routine preventive exam is a medical exam given for a reason other than to diagnose or treat a suspected or
identified illness or injury and also includes:
• Evidence-based items that have in effect a rating of A or B in the current recommendations of the
United States Preventive Services Task Force.
• Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and
Services Administration guidelines for children and adolescents.
• Screenings and counseling services as provided for in the comprehensive guidelines recommended by
the Health Resources and Services Administration. These services may include but are not limited to:
- Screening and counseling services on topics such as:
o Interpersonal and domestic violence
o Sexually transmitted diseases
o Human immune deficiency virus (HIV) infections
- High risk human papillomavirus (HPV) DNA testing for women
AL HCOC 08 as amended by 20
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Covered services include:
• Office visit to a physician
• Hearing screening
• Vision screening
• Radiological services, lab and other tests
• For covered newborns, an initial hospital checkup
Well woman preventive visits
A routine well woman preventive exam is a medical exam given for a reason other than to diagnose or treat a
suspected or identified illness or injury and also includes:
• Office visit to a physician, PCP, OB, GYN or OB/GYN for services including Pap smears
• Preventive care breast cancer (BRCA) gene blood testing
• Screening for diabetes after pregnancy for women with a history of diabetes during pregnancy
• Screening for urinary incontinence
Prosthetic device
A prosthetic device is a device that temporarily or permanently replaces all or part of an external body part lost
or impaired as a result of illness, injury or congenital defects.
Covered services include the initial provision and subsequent replacement of a prosthetic device that your
physician orders and administers.
Coverage includes:
• Instruction and other services (such as attachment or insertion) so you can properly use the device
• Repairing or replacing the original device you outgrow or that is no longer appropriate because your
physical condition changed
• Replacements required by ordinary wear and tear or damage
You may receive a prosthetic device as part of another covered service and therefore it will not be covered
under this benefit.
The following are not covered services:
• Orthopedic shoes and therapeutic shoes, unless the orthopedic shoe is an integral part of a covered leg
brace
• Trusses, corsets, and other support items
• Repair and replacement due to loss, misuse, abuse or theft
Reconstructive breast surgery and supplies
Covered services include all stages of reconstructive surgery by your provider and related supplies provided in
an inpatient or outpatient setting only in the following circumstances:
• Your surgery reconstructs the breast where a necessary mastectomy was performed, such as an implant
and areolar reconstruction. It also includes:
- Surgery on a healthy breast to make it symmetrical with the reconstructed breast
- Treatment of physical complications of all stages of the mastectomy, including lymphedema
- Prostheses
AL HCOC 08 as amended by 21
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Reconstructive surgery and supplies
Covered services include all stages of reconstructive surgery by your provider and related supplies provided in
an inpatient or outpatient setting only in the following circumstances:
• Your surgery is to implant or attach a covered prosthetic device.
• Your surgery corrects a gross anatomical defect present at birth. The surgery will be covered if:
- The defect results in severe facial disfigurement or major functional impairment of a body part
- The purpose of the surgery is to improve function
• Your surgery is needed because treatment of your illness resulted in severe facial disfigurement or
major functional impairment of a body part, and your surgery will improve function.
Covered services also include the procedures or surgery to sound natural teeth, injured due to an accident and
performed as soon as medically possible, when:
• The teeth were stable, functional and free from decay or disease at the time of the injury.
• The surgery or procedure returns the injured teeth to how they functioned before the accident.
These dental related services are limited to:
• The first placement of a permanent crown or cap to repair a broken tooth
• The first placement of dentures or bridgework to replace lost teeth
• Orthodontic therapy to pre-position teeth
Short-term cardiac and pulmonary rehabilitation services
Cardiac rehabilitation
Covered services include cardiac rehabilitation services you receive at a hospital, skilled nursing facility or
physician’s office, but only if those services are part of a treatment plan determined by your risk level and
ordered by your physician.
Pulmonary rehabilitation
Covered services include pulmonary rehabilitation services as part of your inpatient hospital stay if they are part
of a treatment plan ordered by your physician. A course of outpatient pulmonary rehabilitation may also be
covered if it is performed at a hospital, skilled nursing facility, or physician’s office, is used to treat reversible
pulmonary disease states, and is part of a treatment plan ordered by your physician.
Short-term rehabilitation services
Short-term rehabilitation services help you restore or develop skills and functioning for daily living. The services
must follow a specific treatment plan, ordered by your physician. The services have to be performed by a:
• Licensed or certified physical, occupational, or speech therapist
• Hospital, skilled nursing facility, or hospice facility
• Home health care agency
• Physician
AL HCOC 08 as amended by 22
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Covered services include:
• Spinal manipulation to correct a muscular or skeletal problem. Your provider must establish or approve
a treatment plan that details the treatment and specifies frequency and duration.
Cognitive rehabilitation, physical, occupational, and speech therapy
Covered services include:
• Physical therapy, but only if it is expected to significantly improve or restore physical functions lost as a
result of an acute illness, injury, or surgical procedure
• Occupational therapy, but only if it is expected to do one of the following:
- Significantly improve, develop, or restore physical functions you lost as a result of an acute illness,
injury, or surgical procedure
- Help you relearn skills so you can significantly improve your ability to perform the activities of daily
living on your own
• Speech therapy, but only if it is expected to do one of the following:
- Significantly improve or restore lost speech function or correct a speech impairment resulting from
an acute illness, injury, or surgical procedure
- Improve delays in speech function development caused by a gross anatomical defect present at
birth (Speech function is the ability to express thoughts, speak words and form sentences. Speech
impairment is difficulty with expressing one’s thoughts with spoken words.)
• Cognitive rehabilitation associated with physical rehabilitation, but only when:
- Your cognitive deficits are caused by neurologic impairment due to trauma, stroke, or
encephalopathy
- The therapy is coordinated with us as part of a treatment plan intended to restore previous
cognitive function
Short-term physical, speech and occupational therapy services provided in an outpatient setting are subject to
the same conditions and limitations for outpatient short-term rehabilitation services. See the Short-term
rehabilitation services section in the schedule of benefits.
The following are not covered services:
• Services provided in an educational or training setting or to teach sign language
• Vocational rehabilitation or employment counseling
Skilled nursing facility
Covered services include precertified inpatient skilled nursing facility care. This includes:
• Room and board, up to the semi-private room rate
• Services and supplies provided during a stay in a skilled nursing facility
AL HCOC 08 as amended by 23
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Telemedicine
Covered services include telemedicine consultations when provided by a physician, specialist, behavioral
health provider or other telemedicine provider acting within the scope of their license.
Covered services for telemedicine consultations are available from a number of different kinds of providers
under your plan. Log in to your member website at https://www.aetna.com/ to review our telemedicine
provider listing and contact us to get more information about your options, including specific cost sharing
amounts.
The following are not covered services:
• Telemedicine kiosks
Tests, images and labs - outpatient
Diagnostic complex imaging services
Covered services include:
• Computed tomography (CT) scans, including for preoperative testing
• Magnetic resonance imaging (MRI) including magnetic resonance spectroscopy (MRS), magnetic
resonance venography (MRV) and magnetic resonance angiogram (MRA)
• Nuclear medicine imaging including positron emission tomography (PET) scans
• Other imaging service where the billed charge exceeds $500
Complex imaging for preoperative testing is covered under this benefit.
Diagnostic lab work
Covered services include:
• Lab
• Pathology
• Other tests
These are covered only when you get them from a licensed radiology provider or lab.
Diagnostic x-ray and other radiological services
Covered services include x-rays, scans and other services (but not complex imaging) only when you get them
from a licensed radiology provider. See Diagnostic complex imaging services above for more information.
Therapies – chemotherapy, GCIT, infusion, radiation
Chemotherapy
Covered services for chemotherapy depend on where treatment is received. In most cases, chemotherapy is
covered as outpatient care. However, your hospital benefit covers the initial dose of chemotherapy after a
cancer diagnosis during a hospital stay.
Gene-based, cellular and other innovative therapies (GCIT)
Covered services include GCIT provided by a physician, hospital or other provider.
Key Terms
Here are some key terms we use in this section. These will help you better understand GCIT.
AL HCOC 08 as amended by 24
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Gene
A gene is a unit of heredity which is transferred from a parent to child and is thought to determine some feature
of the child.
Molecular
Molecular means relating to or consisting of molecules. A molecule is a group of atoms bonded together, making
the smallest vital unit of a chemical compound that can take part in a chemical reaction.
Therapeutic
Therapeutic means a treatment, therapy, or drug meant to have a good effect on the body or mind; adding to a
sense of well-being.
GCIT are defined as any services that are:
• Gene-based
• Cellular and innovative therapeutics
The services have a basis in genetic/molecular medicine and are not covered under the Institutes of Excellence™
(IOE) programs. We call these “GCIT services.”
GCIT covered services include:
• Cellular immunotherapies.
• Genetically modified viral therapy.
• Other types of cells and tissues from and for use by the same person (autologous) and cells and tissues
from one person for use by another person (allogenic) for treatment of certain conditions.
• All human gene-based therapy that seeks to change the usual function of a gene or alter the biologic
properties of living cells for therapeutic use. Examples include therapies using:
− Luxturna® (Voretigene neparvovec)
− Zolgensma® (Onasemnogene abeparvovec-xioi)
− Spinraza® (Nusinersen)
• Products derived from gene editing technologies, including CRISPR-Cas9.
• Oligonucleotide-based therapies. Examples include:
− Antisense. An example is Spinraza (Nusinersen).
− siRNA.
− mRNA.
− microRNA therapies.
AL HCOC 08 as amended by 25
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Facilities/provider for gene-based, cellular and other innovative therapies
We designate facilities to provide GCIT services or procedures. GCIT physicians, hospitals and other providers
are GCIT-designated facilities/providers for Aetna and CVS Health.
Important note:
The amount you will pay for GCIT covered services depends on where you get the care. Your cost share will be
lower when you get GCIT covered services from the facility/provider we designate. Covered services received
from a GCIT-designated facility/provider are subject to the network copayment, coinsurance, deductible,
maximum out-of-pocket and limits, unless otherwise stated in this certificate and the schedule of benefits.
You may also get GCIT covered services from a non-designated facility/provider, but your cost share will be
higher. Covered services received from a non-designated GCIT facility/provider are subject to the out-of-
network copayment, coinsurance, deductible, maximum out-of-pocket, and limits, unless otherwise stated in
this certificate and the schedule of benefits. If there are no GCIT-designated facilities/providers assigned in
your network it’s important that you contact us so we can help you determine if there are other facilities that
may meet your needs.
Infusion therapy
Infusion therapy is the intravenous (IV) administration of prescribed medications or solutions. Covered services
include infusion therapy you receive in an outpatient setting including but not limited to:
• A freestanding outpatient facility
• The outpatient department of a hospital
• A physician’s office
• Your home from a home care provider
You can access the list of preferred infusion locations by contacting us.
When Infusion therapy services and supplies are provided in your home, they will not count toward any
applicable home health care maximums.
Certain infused medications may be covered under the outpatient prescription drug benefit. You can access the
list of specialty prescription drugs by contacting us.
Radiation therapy
Covered services include the following radiology services provided by a health professional:
• Accelerated particles
• Gamma ray
• Mesons
• Neutrons
• Radioactive isotopes
• Radiological services
• Radium
AL HCOC 08 as amended by 26
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Transplant services
Covered services include transplant services provided by a physician and hospital.
This includes the following transplant types:
• Solid organ
• Hematopoietic stem cell
• Bone marrow
• CAR-T and T Cell receptor therapy for FDA-approved treatments
• Thymus tissue for FDA-approved treatments
Network of transplant facilities
We designate facilities to provide specific services or procedures. They are listed as Institutes of Excellence™
(IOE) facilities in your provider directory.
The amount you will pay for covered transplant services depends on where you get the care. Your cost share will
be lower when you get transplant services from the facility we designate to perform the transplant you need.
Transplant services received from an IOE facility are subject to the network copayment, coinsurance,
deductible, maximum out-of-pocket and limits, unless stated differently in this certificate and schedule of
benefits. You may also get transplant services at a non-IOE facility, but your cost share will be higher. Transplant
services received from a non-IOE facility are subject to the out-of-network copayment, coinsurance, deductible,
maximum out-of-pocket, and limits, unless stated differently in this certificate and schedule of benefits.
Important note:
If there are no IOE facilities assigned to perform your transplant type in your network, it’s important that
you contact us so we can help you determine if there are other facilities that may meet your needs. If you
don’t get your transplant services at the facility we designate, your cost share will be higher.
Many pre and post-transplant medical services, even routine ones, are related to and may affect the success
of your transplant. If your transplant care is being coordinated by the National Medical Excellence
®
(NME)
program, all medical services must be managed through NME so that you receive the highest level of
benefits at the appropriate facility. This is true even if the covered service is not directly related to your
transplant.
The following are not covered services:
• Services and supplies furnished to a donor when the recipient is not a covered person
• Harvesting and storage of organs, without intending to use them for immediate transplantation for your
existing illness
• Harvesting and/or storage of bone marrow, hematopoietic stem cells, or other blood cells without
intending to use them for transplantation within 12 months from harvesting, for an existing illness
AL HCOC 08 as amended by 27
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Urgent ca re services
Covered services include services and supplies to treat an urgent condition at an urgent care center. An “urgent
care center” is a facility licensed as a freestanding medical facility to treat urgent conditions. Urgent conditions
need prompt medical attention but are not life-threatening.
If you go to an urgent care center for what is not an urgent condition, the plan may not cover your expenses.
See the schedule of benefits for more information.
Covered services include services and supplies to treat an urgent condition at an urgent care center as
described below:
• Urgent condition within the network (in-network)
‒ If you need care for an urgent condition, you should first seek care through your physician, PCP. If
your physician is not reasonably available, you may access urgent care from an urgent care center
that is in-network.
• Urgent condition outside the network (out-of-network)
‒ You are covered for urgent care obtained from a facility that is out-of-network if you are temporarily
unable to get services in-network and getting the health care service cannot be delayed.
The following are not covered services:
• Non-urgent care in an urgent care center
Vision care
Covered services include:
• Routine vision exam provided by an ophthalmologist or optometrist including refraction and glaucoma
testing
The following are not covered services:
• Office visits to an ophthalmologist, optometrist or optician related to the fitting of prescription contact
lenses
• Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for cosmetic
purposes
Walk-in clinic
Covered services include, but are not limited to, health care services provided through a walk-in clinic for:
• Scheduled and unscheduled visits for illnesses and injuries that are not emergency medical conditions
• Preventive care immunizations administered within the scope of the clinic’s license
• Telemedicine consultation
• Individual screening and counseling services that will help you:
- With obesity or healthy diet
- To stop using tobacco products
AL HCOC 08 as amended by 28
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
General plan exclusions
The following are not covered services under your plan:
Behavioral health treatment
Services for the following based on categories, conditions, diagnoses, or equivalent terms as listed in the most
recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric
Association:
• Stay in a facility for treatment for dementia and amnesia without a behavioral disturbance that
necessitates mental health treatment
• School and/or education service, including special education, remedial education, wilderness treatment
programs, or any such related or similar programs
• Services provided in conjunction with school, vocation, work or recreational activities
• Transportation
• Sexual deviations and disorders except as described in the Coverage and exclusions section
• Tobacco use disorders and nicotine dependence except as described in the Coverage and exclusions-
Preventive care section
Blood, blood plasma, synthetic blood, blood derivatives or substitutes
Examples of these are:
• The provision of blood to the hospital, other than blood derived clotting factors
• Any related services including processing, storage or replacement expenses
• The service of blood donors, including yourself, apheresis or plasmapheresis
• The blood you donate for your own use, excluding administration and processing expenses and except
where described in the Coverage and exclusions, Transplant services section
Cosmetic services a nd plastic surgery
Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or enhance the shape or
appearance of the body, except where described in the Coverage and exclusions section
Cost share waived
Any cost for a service when any out-of-network provider waives all or part of your copayment,
coinsurance, deductible, or any other amount
Court-ordered services and supplies
This includes court-ordered services and supplies, or those required as a condition of parole, probation, release
or because of any legal proceeding, unless they are a covered service under your plan
AL HCOC 08 as amended by 29
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Custodial care
Services and supplies meant to help you with activities of daily living or other personal needs.
Examples of these are:
• Routine patient care such as changing dressings, periodic turning and positioning in bed
• Administering oral medications
• Care of stable tracheostomy (including intermittent suctioning)
• Care of a stable colostomy/ileostomy
• Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
• Care of a bladder catheter, including emptying or changing containers and clamping tubing
• Watching or protecting you
• Respite care, adult or child day care, or convalescent care
• Institutional care, including room and board for rest cures, adult day care and convalescent care
• Help with walking, grooming, bathing, dressing, getting in or out of bed, going to the bathroom, eating,
or preparing foods
• Any other services that a person without medical or paramedical training could be trained to perform
Dental services
The following are not covered services:
• Services normally covered under a dental plan
• Dental implants
Educational services
Examples of these are:
• Any service or supply for education, training or retraining services or testing. This includes:
‒ Special education
‒ Remedial education
‒ Wilderness treatment programs (whether or not the program is part of a residential treatment
facility or otherwise licensed institution)
‒ Job training
‒ Job hardening programs
• Educational services, schooling or any such related or similar program, including therapeutic programs
within a school setting.
Examinations
Any health or dental examinations needed:
• Because a third party requires the exam. Examples include examinations to get or keep a job, and
examinations required under a labor agreement or other contract.
• To buy insurance or to get or keep a license.
• To travel
• To go to a school, camp, sporting event, or to join in a sport or other recreational activity.
Experimental or investigational
Experimental or investigational drugs, devices, treatments or procedures unless otherwise covered under
clinical trials.
AL HCOC 08 as amended by 30
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Foot care
Routine services and supplies for the following:
• Routine pedicure services, such as routine cutting of nails, when there is no illness or injury in the nails
• Supplies (including orthopedic shoes), ankle braces, guards, protectors, creams, ointments and other
equipment, devices and supplies
• Treatment of calluses, bunions, toenails, hammertoes or fallen arches
• Treatment of weak feet, chronic foot pain or conditions caused by routine activities, such as walking,
running, working, or wearing shoes
Foot orthotic devices
Foot orthotics or other devices to support the feet, such as arch supports and shoe inserts, unless required for
the treatment of or to prevent complications of diabetes
Gene-based, cellular and other innovative therapies (GCIT)
The following are not covered services unless you receive prior written approval from us:
• All associated services when GCIT services are not covered. Examples include:
− Infusion
− Lab
− Radiology
− Anesthesia
− Nursing services
See the How your plan works – Medical necessity and precertification requirements section.
Growth/height care
• A treatment, device, drug, service or supply to increase or decrease height or alter the rate of growth
• Surgical procedures, devices and growth hormones to stimulate growth
Maintenance care
Care made up of services and supplies that maintain, rather than improve, a level of physical or mental function,
except for habilitation therapy services
Medical supplies – outpatient disposable
Any outpatient disposable supply or device. Examples of these include:
• Sheaths
• Bags
• Elastic garments
• Support hose
• Bandages
• Bedpans
• Home test kits not related to diabetic testing
• Splints
• Neck braces
• Compresses
• Other devices not intended for reuse by another patient
AL HCOC 08 as amended by 31
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Missed appointments
Any cost resulting from a canceled or missed appointment
Nutritional support
Any food item, including:
• Infant formulas
• Nutritional supplements
• Vitamins
• Prescription vitamins
• Medical foods
• Other nutritional items
Obesity surgery and services
Weight management treatment or drugs intended to decrease or increase body weight, control weight or treat
obesity, including morbid obesity except as described in the Coverage and exclusions section, including
preventive services for obesity screening and weight management interventions. This is regardless of the
existence of other medical conditions. Examples of these are:
• Liposuction, banding, gastric stapling, gastric by-pass and other forms of bariatric surgery
• Surgical procedures, medical treatments and weight control/loss programs primarily intended to treat,
or are related to the treatment of obesity, including morbid obesity
• Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food
supplements, appetite suppressants and other medications
• Hypnosis, or other forms of therapy
• Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy or
other forms of activity or activity enhancement
Other non-covered services
• Services you have no legal obligation to pay
• Services that would not otherwise be charged if you did not have the coverage under the plan
Other primary payer
Payment for a portion of the charges that Medicare or another party is responsible for as the primary payer
Personal care, comfort or convenience items
Any service or supply primarily for your convenience and personal comfort or that of a third party
Prescription or non-prescription drugs and medicines - outpatient
• Outpatient prescription or non-prescription drugs and medicines provided by the policyholder or
through a third party vendor contract with the policyholder
• Drugs that are included on the list of specialty prescription drugs as covered under your outpatient
prescription drug plan
AL HCOC 08 as amended by 32
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Routine exams
Routine physical exams, routine eye exams, routine dental exams, routine hearing exams and other preventive
services and supplies, except as specifically provided in the Covered services and exclusions section
Services provided by a family member
Services provided by a spouse, civil union partner, domestic partner, parent, child, stepchild, brother, sister, in-
law, or any household member
Services, supplies and drugs received outside of the United States
Non-emergency medical services, outpatient prescription drugs or supplies received outside of the United
States. They are not covered even if they are covered in the United States under this certificate.
Sexual dysfunction and enhancement
Any treatment, prescription drug, or supply to treat sexual dysfunction, enhance sexual performance or increase
sexual desire, including:
• Surgery, prescription drugs, implants, devices or preparations to correct or enhance erectile function,
enhance sensitivity or alter the shape of a sex organ
• Sex therapy, sex counseling, marriage counseling, or other counseling or advisory services
Strength and performance
Services, devices and supplies such as drugs or preparations designed primarily to enhance your strength,
physical condition, endurance or physical performance
Therapies and tests
• Full body CT scans
• Hair analysis
• Hypnosis and hypnotherapy
• Massage therapy, except when used for physical therapy treatment
• Sensory or hearing and sound integration therapy
Tobacco cessation
Any treatment, drug, service or supply to stop or reduce smoking or the use of other tobacco products or to
treat or reduce nicotine addiction, dependence or cravings, including, medications, nicotine patches and gum
unless recommended by the United States Preventive Services Task Force (USPSTF). This also includes:
• Counseling, except as specifically provided in the Covered services and exclusions section
• Hypnosis and other therapies
• Medications, except as specifically provided in the Covered services and exclusions section
• Nicotine patches
• Gum
Treatment i n a federal, state, or governmental entity
Any care in a hospital or other facility owned or operated by any federal, state or other governmental entity
unless coverage is required by applicable laws
AL HCOC 08 as amended by 33
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Voluntary sterilization
• Reversal of voluntary sterilization procedures, including related follow-up care
Wilderness treatment programs
See Educational services in this section
Work related illness or injuries
Coverage available to you under workers’ compensation or a similar program under local, state or federal law
for any illness or injury related to employment or self-employment
Important note:
A source of coverage or reimbursement is considered available to you even if you waived your right to
payment from that source. You may also be covered under a workers’ compensation law or similar law. If
you submit proof that you are not covered for a particular illness or injury under such law, then that illness
or injury will be considered “non-occupational” regardless of cause.
AL HCOC 08 as amended by 34
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
How your plan works
How your medical plan works while you are covered in-network
Your in-network coverage:
• Helps you get and pay for a lot of – but not all – health care services
Your cost share is lower when you use a network provider.
Providers
Our provider network is there to give you the care you need. You can find network providers and see important
information about them most easily on our online provider directory. Just log in to the Aetna website.
You may choose a PCP to oversee your care. Your PCP will provide routine care and send you to other providers
when you need specialized care. You don’t have to get care through your PCP. You may go directly to network
providers. Your plan may pay a bigger share for covered services you get through your PCP, so choose a PCP as
soon as you can.
For more information about the network and the role of your PCP, see the Who provides the care section.
Service a rea
Your plan generally pays for covered services only within a specific geographic area, called a service area. There
are some exceptions, such as for emergency services, urgent care, and transplant services.
See the Who provides the care section below.
How your medical plan works while you are covered out-of-network
With your out-of-network coverage:
• You can get care from providers who are not part of the Aetna network and from network providers
without a PCP referral
• You may have to pay the full cost for your care, and then submit a claim to be reimbursed
• You are responsible to get any required precertification
• Your cost share will be higher
Keeping a provider you go to now (continuity of care)
You may have to find a new provider when:
• You join the plan and the provider you have now is not in the network
• You are already an Aetna member and your provider stops being in our network
However, in some cases, you may be able to keep going to your current provider to complete a treatment or to
have treatment that was already scheduled. This is called continuity of care.
If this situation applies to you, contact us for details. If we approve your request to keep going to your current
provider, we will tell you how long you can continue to see the provider. If you are pregnant and have entered
your second trimester, this will include the time required for postpartum care directly related to the delivery.
We will authorize coverage only if the provider agrees to our usual terms and conditions for contracting
providers.
Who provides the care
AL HCOC 08 as amended by 35
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Network providers
We have contracted with providers in the service area to provide covered services to you. These providers
make up the network for your plan.
To get network benefits, you must use network providers. There are some exceptions:
• Emergency services – see the description of emergency services in the Coverage and exclusions section.
• Urgent care – see the description of urgent care in the Coverage and exclusions section.
• Transplants – see the description of transplant services in the Coverage and exclusions section.
You may select a network provider from the online directory through your member website.
You will not have to submit claims for services received from network providers. Your network provider will
take care of that for you. And we will pay the network provider directly for what the plan owes.
Your PCP
We encourage you to get covered services through a PCP. They will provide you with primary care.
How you choose your PCP
You can choose a PCP from the list of PCPs in our directory.
Each covered family member is encouraged to select a PCP. You may each choose a different PCP. You should
select a PCP for your covered dependent if they are a minor or cannot choose a PCP on their own.
What your PCP will do for you
Your PCP will coordinate your medical care or may provide treatment. They may send you to other network
providers.
Changing your PCP
You may change your PCP at any time by contacting us.
Out-of-network providers
You can also get care from out-of-network providers. When you use an out-of-network provider, your cost
share is higher. You are responsible for:
• Your out-of-network deductible
• Your out-of-network coinsurance
• Any charges over the allowable amount
• Submitting your own claims and getting precertification
Keeping a provider you go to now (continuity of care)
You may have to find a new provider when:
• You join the plan and the provider you have now is not in the network
• You are already an Aetna member and your provider stops being in our network
But, in some cases, you may be able to keep going to your current provider to complete a treatment or to have
treatment that was already scheduled. This is called continuity of care.
If this situation applies to you, contact us for details. If the provider didn’t leave the network based on fraud,
lack of quality standards, or our termination of the provider, you’ll be able to receive transitional care from your
AL HCOC 08 as amended by 36
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
provider for a period up to 90 days from when we notified you of their network status or the end of your
treatment, whichever is sooner.
Important note:
If you are pregnant and have entered your second trimester, transitional care will be through the time required
for postpartum care directly related to the delivery.
You will not be responsible for an amount that exceeds the cost share that would have applied had your
provider remained in the network.
Medical necessity and precertification requirements
Your plan pays for its share of the expense for covered services only if the general requirements are met. They
are:
• The service is medically necessary
• For in-network benefits, you get the service from a network provider
• You or your provider precertifies the service when required
Medically necessary, medical necessity
The medical necessity requirements are in the Glossary section, where we define “medically necessary, medical
necessity.” That is where we also explain what our medical directors or a physician they assign consider when
determining if a service is medically necessary.
Important note:
We cover medically necessary, sex-specific covered services regardless of identified gender.
Precertification
You need pre-approval from us for some covered services. Pre-approval is also called precertification.
In-network
Your network physician is responsible for obtaining any necessary precertification before you get the care.
Network providers cannot bill you if they fail to ask us for precertification. But if your physician requests
precertification and we deny it, and you still choose to get the care, you will have to pay for it yourself.
Out-of-network
When you go to an out-of-network provider, you are responsible to get any required precertification from us. If
you don’t precertify:
• Your benefits may be reduced, or the plan may not pay. See your schedule of benefits for details.
• You will be responsible for the unpaid bills.
• Your additional out-of-pocket expenses will not count toward your deductible or maximum out-of-
pocket limit if you have any.
Timeframes for precertification are listed below. For emergency services, precertification is not required, but
you should notify us as shown.
To obtain precertification, contact us. You, your physician or the facility must call us within these timelines:
AL HCOC 08 as amended by 37
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Type of care
Timeframe
Non-emergency admission
Call at least 14 days before the date you are
scheduled to be admitted
Emergency admission
Call within 48 hours or as soon as reasonably
possible after you have been admitted
Urgent admission
Call before you are scheduled to be admitted
Outpatient non-emergency medical services
Call at least 14 days before the care is provided,
or the treatment or procedure is scheduled
An urgent admission is a hospital admission by a physician due to the onset of or change in an illness, the
diagnosis of an illness, or injury.
We will tell you and your physician in writing of the precertification decision, where required by state law. An
approval is valid for 180 days as long as you remain enrolled in the plan.
For an inpatient stay in a facility, we will tell you, your physician and the facility about your precertified length
of stay. If your physician recommends that you stay longer, the extra days will need to be precertified. You, your
physician, or the facility will need to call us as soon as reasonably possible, but no later than the final authorized
day. We will tell you and your physician in writing of an approval or denial of the extra days.
If you or your provider request precertification and we don’t approve coverage, we will tell you why and explain
how you or your provider may request review of our decision. See the Claim decisions, grievances and appeal
procedures section.
Types of services that require precertification
Precertification is required for inpatient stays and certain outpatient services and supplies.
Precertification is required for the following types of services and supplies:
Inpatient –
• Gender affirming treatment
• Gene-based, cellular and other innovative therapies (GCIT)
• Obesity (bariatric) surgery
• Stays in a hospice facility
• Stays in a hospital
• Stays in a rehabilitation facility
• Stays in a residential treatment facility for treatment of mental health disorders and substance related
disorders
• Stays in a skilled nursing facility
Outpatient –
• ART services
• Complex imaging
• Comprehensive infertility services
• Cosmetic and reconstructive surgery
• Gender affirming treatment
• Gene-based, cellular and other innovative therapies (GCIT)
• Injectables, (immunoglobulins, growth hormones, multiple sclerosis medications, osteoporosis
AL HCOC 08 as amended by 38
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
medications, Botox, hepatitis C medications)
• Kidney dialysis
• Knee surgery
• Non-emergency transportation by airplane
• Outpatient back surgery not performed in a physician’s office
• Partial hospitalization treatment – mental health disorders and substance related disorders treatment
• Private duty nursing services
• Sleep studies
• Transcranial magnetic stimulation (TMS)
• Wrist surgery
Contact us to get a complete list of the services that require precertification. The list may change from time to
time.
Sometimes you or your provider may want us to review a service that doesn't require precertification before
you get care. This is called a predetermination, and it is different from precertification. Predetermination means
that you or your provider requests the pre-service clinical review of a service that does not require
precertification.
Our clinical policy bulletins explain our policy for specific services and supplies. We use these bulletins and other
resources to help guide individualized coverage decisions under our plans. You can find the bulletins and other
information at https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html.
Certain prescription drugs are covered under the medical plan when they are given to you by your doctor or
health care facility. The following precertification information applies to these prescription drugs:
• For certain drugs, your provider needs to get approval from us before we will cover the drug. The
requirement for getting approval in advance guides appropriate use of certain drugs and makes sure
they are medically necessary.
Step therapy is a type of precertification where you must try one or more prerequisite drugs before a step
therapy drug is covered. A ‘prerequisite’ is something that is required before something else. Prerequisite drugs
are FDA-approved, may cost less and treat the same condition. If you don’t try the prerequisite drugs first, the
step therapy drug may not be covered.
Contact us or go online to get the most up-to-date precertification requirements and list of step therapy drugs.
Requesting a medical exception
Sometimes you or your provider may ask for a medical exception for drugs that are not covered or for which
coverage was denied. You, someone who represents you or your provider can contact us. You will need to
provide us with clinical documentation. Any exception granted is based upon an individual and is a case-by-case
decision that will not apply to other members. For directions on how you can submit a request for a review:
• Contacting our Precertification Department at 1-855-582-2025
• Faxing the request to 1-855-330-1716
• Submitting the request in writing to CVS Health ATTN: Aetna PA, 1300 E Campbell Road Richardson,
TX 75081
You, someone who represents you or your provider may seek a quicker medical exception when the situation is
urgent. It’s an urgent situation when you have a health condition that may seriously affect your life, health, or
AL HCOC 08 as amended by 39
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
ability to get back maximum function. It can also be when you are going through a current course of treatment
using a non-covered drug.
What the plan pays and what y ou pay
Who pays for your covered services – this plan, both of us, or just you? That depends.
The g eneral rule
The schedule of benefits lists what you pay for each type of covered service. In general, this is how your benefit
works:
• You pay the deductible, when it applies.
• Then the plan and you share the expense. Your share is called a copayment or coinsurance.
• Then the plan pays the entire expense after you reach your maximum out-of-pocket limit.
When we say “expense” in this general rule, we mean the negotiated charge for a network provider, and
allowable amount for an out-of-network provider.
Negotiated charge
For health coverage:
This is the amount a network provider has agreed to accept or that we have agreed to pay them or a third party
vendor (including any administrative fee in the amount paid).
For surprise billing, calculations will be made based on the median contracted rate.
We may enter into arrangements with network providers or others related to:
• The coordination of care for members
• Improving clinical outcomes and efficiencies
Some of these arrangements are called:
• Value-based contracting
• Risk sharing
• Accountable care arrangements
These arrangements will not change the negotiated charge under this plan.
For prescription drug services:
When you get a prescription drug, we have agreed to this amount for the prescription or paid this amount to
the network pharmacy or third party vendor that provided it. The negotiated charge may include a rebate,
additional service or risk charges and administrative fees. It may include additional amounts paid to or received
from third parties under price guarantees.
Allowable a mount
This is the amount of an out-of-network provider’s charge that is eligible for coverage. You are responsible for
all charges above this amount. The allowable amount depends on the geographic area where you get the
service or supply. Allowable amount doesn’t apply to involuntary services. These are services or supplies that
are:
• Provided at a network facility by an out-of-network provider
AL HCOC 08 as amended by 40
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
• Not available from a network provider
• An emergency service
The table below shows the method for calculating the allowable amount for specific services or supplies:
Service or supply:
Allowable amount is based on:
Professional services and other services or
supplies not mentioned below
XX% of Medicare allowed rate
Services of hospitals and other facilities
XX% of Medicare allowed rate
Prescription drugs
110% of average wholesale price (AWP)
Prescription drugs for gene-based, cellular and
other innovative therapies (GCIT)
110% of average wholesale price (AWP)
Important note:
See Special terms used, below, for a description of what the allowable amount is based on.
If the provider bills less than the amount calculated using a method above, the allowable amount is what the
provider bills.
Special terms used:
• Average wholesale price (AWP) is the current average wholesale price of a prescription drug as listed in
the Facts & Comparisons®, Medi-Span daily price updates or any other similar publication we choose to
use.
• Facility charge review (FCR) rate is an amount that we determine is enough to cover the facility
provider’s estimated costs for the service and leave the provider with a reasonable profit. This means
for:
- Hospitals and other facilities that report costs or cost to charge ratios to The Centers for Medicare &
Medicaid Services (CMS), the FCR rate is based on what the facilities report to CMS
- Facilities that don’t report costs or cost to charge ratios to CMS, the FCR rate is based on a statewide
average of these facilities
We may adjust the formula as needed to maintain the reasonableness of the allowable amount. For
example, we may make an adjustment if we determine that in a state the charges of a specific type of
facility are much higher than charges of facilities that report to CMS.
• Geographic area is normally based using the first three digits of a zip code. If we believe we need more
data for a particular service or supply, we may base rates on a wider geographic area such as the entire
state.
• Medicare allowed rates are the rates CMS establishes for services and supplies provided to Medicare
enrollees without taking into account adjustments for specific provider performance. We update our
system with these when revised within 180 days of receiving them from CMS. If Medicare doesn’t have a
rate, we use one or more of the items below to determine the rate for a service or supply:
- The method CMS uses to set Medicare rates
- How much other providers charge or accept as payment
- How much work it takes to perform a service
- Other things as needed to decide what rate is reasonable
We may make the following exceptions:
- For inpatient services, our rate may exclude amounts CMS allows for operating Indirect Medical
Education (IME) and Direct Graduate Medical Education (DGME) programs
- Our rate may exclude other payments that CMS may make directly to hospitals or other
providers and backdated adjustments
AL HCOC 08 as amended by 41
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
- For anesthesia, our rate may be at least 105% of the rate CMS establishes
- For lab, our rate may be 75% of the rate CMS establishes
- For DME, our rate may be 75% of the rate CMS establishes
For medications that are paid as a medical benefit instead of a pharmacy benefit, our rate may be 100%
of the rates CMS establishes.
When the allowable amount is based on a percentage of the Medicare allowed rate, it is not affected by
adjustments or incentives given to providers under Medicare programs.
Our reimbursement policies
We have the right to apply our reimbursement policies to all out-of-network services including involuntary
services. This may affect the allowable amount. When we do this, we consider:
• The length and difficulty of a service
• Whether additional expenses are needed, when multiple procedures are billed at the same time
• Whether an assistant surgeon is needed
• If follow up care is included
• Whether other conditions change or make a service unique
• Whether any of the services described by a claim line are part of or related to the primary service
provided, when a charge includes more than one claim line
• The educational level, licensure or length of training of the provider
We base our reimbursement policies on our review of:
• CMS National Correct Coding Initiative (NCCI) and other external materials that say what billing and
coding practices are and aren’t appropriate
• Generally accepted standards of medical and dental practice
• The views of physicians and dentists practicing in relevant clinical areas
We use commercial software to administer some of these policies. Policies may differ for professional services
and facility services.
Get the most from your benefits:
We have online tools to help you decide whether to get care and if so, where. Log in to your member
website. The website contains additional information that can help you determine the cost of a service or
supply.
Surprise bill
There may be times when you unknowingly receive services or don’t consent to receive services from an out-of-
network provider, even when you try to stay in the network for your covered services. You may get a bill at the
out-of-network rate that you didn’t expect. This is called a surprise bill.
An out-of-network provider can’t balance bill or attempt to collect costs from you that exceed your in-network
cost-sharing requirement, such as deductibles, copayments and coinsurance for the following services:
• Emergency services provided by an out-of-network provider
• Non-emergency surgical or ancillary services provided by an out-of-network provider at an in-network
facility, except when the out-of-network provider has given you the following:
− The out-of-network notice for your signature
AL HCOC 08 as amended by 42
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
− The estimated charges for the items and services
− Notice that the provider is an out-of-network provider
• Out-of-network air ambulance services
The out-of-network provider must get your consent to be treated and balance billed by them.
Surgical or ancillary services mean any professional services including:
• Anesthesiology
• Hospitalist services
• Laboratory services
• Pathology
• Radiology
• Surgery
A facility in this instance means an institution providing health care related services, or a health care setting.
This includes the following:
• Hospitals and other licensed inpatient centers
• Ambulatory surgical or treatment centers
• Skilled nursing facilities
• Residential treatment facilities
• Diagnostic, laboratory, and imaging centers
• Rehabilitation facilities
• Other therapeutic health settings
A surprise bill claim is paid based on the median contracted rate for all plans offered by us in the same insurance
market for the same or similar item or service that is all of the following:
• Provided by a provider in the same or similar specialty or facility of the same or similar facility type
• Provided in the geographic region in which the item or service is furnished
The median contracted rate is subject to additional adjustments as specified in federal regulations.
Any cost share paid with respect to the items and services will apply toward your in-network deductible and
maximum out-of-pocket limit if you have one.
It is not a surprise bill when you knowingly choose to go out-of-network and have signed a consent notice for
these services. In this case, you are responsible for all charges.
You may request external review if you want to know if the federal surprise bill law applies to your situation.
If you receive a surprise bill or have any questions about what a surprise bill is, contact us.
Paying for covered services – the g eneral requirements
There are several general requirements for the plan to pay any part of the expense for a covered service. For in-
network coverage, they are:
• The service is medically necessary
• You get your care from a network provider
• You or your provider precertifies the service when required
AL HCOC 08 as amended by 43
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
For out-of-network coverage:
• The service is medically necessary
• You get your care from an out-of-network provider
• You or your provider precertifies the service when required
For outpatient prescription drugs, your costs are based on:
• The type of prescription you’re prescribed
• Where you fill the prescription
The plan may make some brand-name prescription drugs available to you at the generic prescription drug cost
share.
Generally, your plan and you share the cost for covered services when you meet the general requirements. But
sometimes your plan will pay the entire expense, and sometimes you will. For details, see your schedule of
benefits and the information below.
You pay the entire expense when:
• You get services or supplies that are not medically necessary.
• Your plan requires precertification, your physician requests it, we deny it and you get the services
without precertification.
• You get care from an out of-network provider and the provider waives all or part of your cost share.
In all these cases, the provider may require you to pay the entire charge. Any amount you pay will not count
towards your deductible or your maximum out-of-pocket limit.
Where y our schedule of benefits fits in
The schedule of benefits shows any out-of-pocket costs you are responsible for when you receive covered
services and any benefit limitations that apply to your plan. It also shows any maximum out-of-pocket limits
that apply.
Limitations include things like maximum age, visits, days, hours, and admissions. Out-of-pocket costs include
things like deductibles, copayments and coinsurance.
Keep in mind that you are responsible for paying your part of the cost sharing. You are also responsible for costs
not covered under this plan.
Coordination of benefits
Some people have health coverage under more than one health plan. If you do, we will work with your other
plan to decide how much each plan pays. This is called coordination of benefits (COB).
Key Terms
Here are some key terms we use in this section. These will help you understand this COB section.
Allowable expense means a health care expense that any of your health plans cover.
In this section when we talk about “plan” through which you may have other coverage for health care expenses
we mean:
AL HCOC 08 as amended by 44
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
• Group or non-group, blanket, or franchise health insurance policies issued by insurers, HMOs, or health
care service contractors
• Labor-management trustee plans, labor organization plans, employer organization plans, or employee
benefit organization plans
• An automobile insurance policy
• Medicare or other government benefits
• Any contract that you can obtain or maintain only because of membership in or connection with a
particular organization or group
How COB works
• When this is your primary plan, we pay your medical claims first as if there is no other coverage.
• When this is your secondary plan:
- We pay benefits after the primary plan and reduce our payment based on any amount the
primary plan paid.
- Total payments from this plan and your other coverage will never add up to more than 100% of
the allowable expenses.
- Each family member has a separate benefit reserve for each year. The benefit reserve balance
is:
o The amount that the secondary plan saved due to COB
o Used to cover any unpaid allowable expenses
o Erased at the end of the year
Determining who pays
The basic rules are listed below. Reading from top to bottom the first rule that applies will determine which plan
is primary and which is secondary. Contact us if you have questions or want more information.
A plan that does not contain a COB provision is always the primary plan.
COB rule
Primary Plan
Secondary plan
Non-dependent or dependent
Plan covering you as an
employee, retired employee or
subscriber (not as a dependent)
Plan covering you as a
dependent
Child – parents married or
living together
Plan of parent whose birthday
(month and day) is earlier in the
year (Birthday rule)
Plan of parent whose
birthday is later in the year
Child – parents separated,
divorced, or not living together
• Plan of parent responsible for
health coverage in court
order
• Birthday rule applies if both
parents are responsible or
have joint custody in court
order
• Custodial parent’s plan if
there is no court order
• Plan of other parent
• Birthday rule applies
(later in the year)
• Non-custodial parent’s
plan
Child – covered by individuals
who are not parents (i.e.
stepparent or grandparent)
Same rule as parent
Same rule as parent
AL HCOC 08 as amended by 45
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
COB rule
Primary Plan
Secondary plan
Active or inactive employee
Plan covering you as an active
employee (or dependent of an
active employee)
Plan covering you as a laid off
or retired employee (or
dependent of a former
employee)
Consolidated Omnibus Budget
Reconciliation Act (COBRA) or
state continuation
Plan covering you as an
employee or retiree (or
dependent of an employee or
retiree)
COBRA or state continuation
coverage
Longer or shorter length of
coverage
Plan that has covered you longer
Plan that has covered you for
a shorter period of time
Other rules do not apply
Plans share expenses equally
Plans share expenses equally
How COB works with Medicare
If your other coverage is under Medicare, federal laws explain whether Medicare will pay first or second. COB
with Medicare will always follow federal requirements. Contact us if you have any questions about this.
When you are eligible for Medicare, we coordinate the benefits we pay with the benefits that Medicare pays. If
you are eligible but not covered, and Medicare would be your primary payer, we may still pay as if you are
covered by Medicare and coordinate with the benefits Medicare would have paid. Sometimes, this plan pays
benefits before Medicare pays. Sometimes, this plan pays benefits after Medicare or after an amount that
Medicare would have paid if you had been covered.
You are eligible for Medicare if you are covered under it. You are also eligible for Medicare even if you are not
covered or if you refused it, dropped it, or didn’t make a request for it.
Effect of prior plan coverage
If you are in a continuation period from a prior plan at the time you join this plan you may not receive the full
benefit paid under this plan. See the schedule of benefits for more information.
Your current plan must be offered through the policyholder.
Other health coverage updates – contact information
You should contact us if you have any changes to your other coverage. We want to be sure our records are
accurate so your claims are processed correctly.
Our rights
We have the right to:
• Release or obtain any information we need for COB purposes, including information we need to recover
any payments from your other health plans
• Reimburse another health plan that paid a benefit we should have paid
• Recover any excess payment from a person or another health plan, if we paid more than we should have
paid
Benefit payments and claims
A claim is a request for payment that you or your health care provider submits to us when you want or get
covered services. There are different types of claims. You or your provider may contact us at various times, to
make a claim, to request approval, or payment, for your benefits. This can be before you receive your benefit,
while you are receiving benefits and after you have received the benefit.
AL HCOC 08 as amended by 46
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
It is important that you carefully read the previous sections within How your plan works. When a claim comes in,
we review it, make a decision and tell you how you and we will split the expense. The amount of time we have
to tell you about our decision on a claim depends on the type of claim.
Claim type and timeframes
Urgent care claim
An urgent claim is one for which the doctor treating you decides a delay in getting medical care could put your
life or health at risk. Or a delay might put your ability to regain maximum function at risk. It could also be a
situation in which you need care to avoid severe pain. We will make a decision within 72 hours.
If you are pregnant, an urgent claim also includes a situation that can cause serious risk to the health of your
unborn baby.
Pre-service claim
A pre-service claim is a claim that involves services you have not yet received and which we will pay for only if
we precertify them. We will make a decision within 15 days.
Post-service claim
A post-service claim is a claim that involves health care services you have already received. We will make a
decision within 30 days.
Concurrent care claim extension
A concurrent care claim extension occurs when you need us to approve more services than we already have
approved. Examples are extending a hospital stay or adding a number of visits to a provider. You must let us
know you need this extension 24 hours before the original approval ends. We will have a decision within 24
hours for an urgent request. You may receive the decision for a non-urgent request within 15 days.
Concurrent care claim reduction or termination
A concurrent care claim reduction or termination occur when we decide to reduce or stop payment for an
already approved course of treatment. We will notify you of such a determination. You will have enough time to
file an appeal. Your coverage for the service or supply will continue until you receive a final appeal decision from
us or an external review organization if the situation is eligible for external review.
During this continuation period, you are still responsible for your share of the costs, such as copayments,
coinsurance and deductibles that apply to the service or supply. If we uphold our decision at the final internal
appeal, you will be responsible for all of the expenses for the service or supply received during the continuation
period.
Filing a claim
When you see a network provider, that office will usually send us a detailed bill for your services. If you see an
out-of-network provider, you may receive the bill (proof of loss) directly. This bill forms the basis of your post-
service claim. If you receive the bill directly, you or your provider must send us the bill within 12 months of the
date you received services, unless you are legally unable to notify us. You must send it to us with a claim form
that you can either get online or contact us to provide. You should always keep your own record of the date,
providers and cost of your services.
The benefit payment determination is made based on many things, such as your deductible or coinsurance, the
AL HCOC 08 as amended by 47
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
necessity of the service you received, when or where you receive the services, or even what other insurance you
may have. We may need to ask you or your provider for some more information to make a final decision. You
can always contact us directly to see how much you can expect to pay for any service.
We will pay a written claim within 30 days and an electronic claim within 15 days from when we receive all the
information necessary. Sometimes we may pay only some of the claim. Sometimes we may deny payment
entirely. We may even rescind your coverage entirely.
We will give you our decision in writing. You may not agree with our decision. There are several ways to have us
review the decisions. Please see the Complaints, claim decisions and appeal procedures section for that
information.
AL HCOC 08 as amended by 48
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Complaints, claim decisions and appeal procedures
The difference between a complaint and an appeal
Complaint
You may not be happy about a provider or an operational issue, and you may want to complain. You can contact
us at any time. This is a complaint. Your complaint should include a description of the issue. You should include
copies of any records or documents you think are important. We will review the information and give you a
written response within 30 calendar days of receiving the complaint. We will let you know if we need more
information to make a decision.
Appeal
When we make a decision to deny services or reduce the amount of money we pay on your care or out-of-
pocket expense, it is an adverse benefit determination. You can ask us to re-review that determination. This is
an appeal. You can start an appeal process by contacting us.
Claim decisions and appeal procedures
Your provider may contact us at various times to make a claim, or to request approval for payment based on
your benefits. This can be before you receive your benefit, while you are receiving benefits and after you have
received the benefit. You may not agree with our decision. As we said in Benefit payments and claims in the How
your plan works section, we pay many claims at the full rate, except for your share of the costs. But sometimes
we pay only some of the claim. Sometimes we deny payment entirely.
Any time we deny even part of the claim, it is an “adverse benefit determination” or “adverse decision.” For any
adverse decision, you will receive an explanation of benefits in writing. You can ask us to review an adverse
benefit determination. This is the internal appeal process. If you still don’t agree, you can also appeal that
decision.
Appeal of an adverse benefit determination
Urgent care or p re-service claim a ppeal
If your claim is an urgent claim or a pre-service claim, your provider may appeal for you without having to fill out
an appeal form. We will give you an answer within 36 hours for an urgent appeal and within 15 calendar days for
a pre-service appeal. A concurrent claim appeal will be addressed according to what type of service and claim it
involves.
Any other claim appeal
You must file an appeal within 180 calendar days from the time you receive the notice of an adverse benefit
determination.
You can appeal by sending a written appeal to the address on the notice of adverse benefit determination, or by
contacting us. You need to include:
• Your name
• The policyholder’s name
• A copy of the adverse benefit determination
• Your reasons for making the appeal
• Any other information you would like us to consider
AL HCOC 08 as amended by 49
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
We will assign your appeal to someone who was not involved in making the original decision. You will receive a
decision within 30 calendar days for a post-service claim.
If you are still not satisfied with the answer, you may make a second internal appeal. You must present your
appeal within 60 calendar days from the date you receive the notice of the first appeal decision.
Another person may submit an appeal for you, including a provider. That person is called an authorized
representative. You need to tell us if you choose to have someone else appeal for you (even if it is your
provider). You should fill out an authorized representative form telling us you are allowing someone to appeal
for you. You can get this form on our website or by contacting us. The form will tell you where to send it to us.
You can use an authorized representative at any level of appeal.
At your last available level of appeal, we will give you any new or additional information we may find and use to
review your claim. There is no cost to you. We will give you the information before we give you our decision.
This decision is called the final adverse benefit determination. You can respond to the information before we tell
you what our final decision is.
Exhaustion of appeal process
In most situations, you must complete the two levels of appeal with us before you can take these other actions:
• Contact the Georgia Department of Insurance to request an investigation of a complaint or appeal
• File a complaint or appeal with the Georgia Department of Insurance
• Appeal through an external review process
• Pursue arbitration, litigation or other type of administrative proceeding
Sometimes you do not have to complete the two levels of appeal before you may take other actions. These
situations are:
• You have an urgent claim or claim that involves ongoing treatment. You can have your claim reviewed
internally and through the external review process at the same time.
• We did not follow all of the claim determination and appeal requirements of the state. But you will not
be able to proceed directly to external review if:
− The rule violation was minor and not likely to influence a decision or harm you
− The violation was for a good cause or beyond our control
− The violation was part of an ongoing, good faith exchange between you and us
External review
External review is a review done by people in an organization outside of Aetna. This is called an external review
organization (ERO).
You have a right to external review only if all the following conditions are met:
• You have received an adverse benefit determination
• Our claim decision involved medical judgement
• We decided the service or supply is not medically necessary, not appropriate, or we decided the service
or supply is experimental or investigational
You may also request external review if you want to know if the federal surprise bill law applies to your
situation.
AL HCOC 08 as amended by 50
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
If our claim decision is one for which you can seek external review, we will say that in the notice of adverse
benefit determination or final adverse benefit determination we send you. That notice also will describe the
external review process. It will include a copy of the request for external review form at the final adverse
determination level.
You must submit the request for external review form:
• To the Georgia Department of Insurance
• Within 4 months of the date you received the decision from us
• With a copy of the notice from us, along with any other important information that supports your
request
You will pay for any information that you send and want reviewed by the ERO. We will pay for information we
send to the ERO plus the cost of the review.
The state will contact the ERO that will conduct the review of your claim.
The ERO will:
• Assign the appeal to one or more independent clinical reviewers that have proper expertise to do the
review
• Consider appropriate credible information that you sent
• Follow our contractual documents and your plan of benefits
• Send notification of the decision within 45 calendar days of the date we receive your request form and
all the necessary information
We will stand by the decision that the ERO makes, unless we can show conflict of interest, bias or fraud.
How long will it take to get an ERO decision?
We will give you the ERO decision not more than 45 calendar days after we receive your notice of external
review form with all the information you need to send in.
Sometimes you can get a faster external review decision. Your provider must call us or send us a request for
external review form.
There are two scenarios when you may be able to get a faster external review:
For initial adverse benefit determinations
• Your provider tells us a delay in receiving health care services would:
− Jeopardize your life, health or ability to regain maximum function
− Be much less effective if not started right away (in the case of experimental or investigational
treatment)
AL HCOC 08 as amended by 51
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
For final adverse determinations
Your provider tells us a delay in receiving health care services would:
• Jeopardize your life, health or ability to regain maximum function
• Be much less effective if not started right away (in the case of experimental or investigational
treatment), or
• The final adverse determination concerns an admission, availability of care, continued stay or health
care service for which you received emergency services, but have not been discharged from a facility
If your situation qualifies for this faster review, you will receive a decision within 72 hours of us getting your
request.
Utilization review
Prescription drugs covered under this plan are subject to misuse, waste or abuse utilization review by us, your
provider or your network pharmacy. The outcome of the review may include:
• Limiting coverage of a drug to one prescribing provider or one network pharmacy
• Quantity, dosage or day supply limits
• Requiring a partial fill or denial of coverage
Recordkeeping
We will keep the records of all complaints and appeals for at least 10 years.
Fees and expenses
We do not pay any fees or expenses incurred by you in pursuing a complaint or appeal.
AL HCOC 08 as amended by 52
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Eligibility, starting and stopping coverage
Eligibility
Who is eligible
The policyholder decides and tells us who is eligible for health coverage.
When you can join the plan
You can enroll:
• At the end of any waiting period the policyholder requires
• Once each year during the annual enrollment period
• At other special times during the year (see the Special times you can join the plan section below)
You can enroll eligible family members (these are your “dependents”) at this time too.
If you don’t enroll when you first qualify for benefits, you may have to wait until the next annual enrollment
period to join.
Who can be a dependent on this plan
You can enroll the following family members:
• Your legal spouse
• Dependent children – yours or your spouse’s
- Dependent children must be:
o Under 26 years of age
- Dependent children include:
o Natural children
o Stepchildren
o Adopted children including those placed with you for adoption
o Foster children
o Children you are responsible for under a qualified medical support order or court order
o Grandchildren in your legal custody
Adding new dependents
You can add new dependents during the year. These include any dependents described in the Who can be a
dependent on this plan section above.
Coverage begins on the date of the event for new dependents that join your plan for the following reasons:
• Birth
• Adoption or placement for adoption
• Marriage
• Legal guardianship
• Court or administrative order
We must receive a completed enrollment form not more than 31 days after the event date.
AL HCOC 08 as amended by 53
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Special times you can join the plan
You can enroll in these situations:
• You didn't enroll before because you had other coverage and that coverage has ended
• Your COBRA coverage has ended
• A court orders that you cover a dependent on your health plan
• When your dependent moves outside the service area for your employee plan
We must receive the completed enrollment information within 31 days of the date when coverage ends.
You can also enroll in these situations:
• You or your dependent lose your eligibility for enrollment in Medicaid or an S-CHIP plan
• You are now eligible for state premium assistance under Medicaid or S-CHIP which will pay your
premium contribution under this plan
We must receive the completed enrollment information within 60 days of the date when coverage ends.
Notification of change in status
Tell us of any changes that may affect your benefits. Please contact us as soon as possible when you have a:
• Change of address
• Dependent status change
• Dependent who enrolls in Medicare or any other health plan
Starting coverage
Your coverage under this plan has a start and an end. You must start coverage after you complete the eligibility
and enrollment process. You can ask your policyholder to confirm your effective date.
Stopping coverage
Your coverage typically ends when you leave your job; but it can happen for other reasons. Ending coverage
doesn’t always mean you lose coverage with us. There will be circumstances that will still allow you to continue
coverage. See the Special coverage options after your coverage ends section.
We will send you notice if your coverage is ending. This notice will tell you the date that your coverage ends.
When will your coverage end
Your coverage under this plan will end if:
• This plan is no longer available
• You ask to end coverage
• The policyholder asks to end coverage
• You are no longer eligible for coverage
• Your work ends
• You stop making required contributions, if any apply
• We end your coverage
• You start coverage under another medical plan offered by your employer
AL HCOC 08 as amended by 54
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
When dependent coverage ends
Dependent coverage will end if:
• A dependent is no longer eligible for coverage.
• You stop making premium contributions, if any apply.
• Your coverage ends for any of the reasons listed above except:
- Exhaustion of your overall maximum benefit.
- You enroll under a group Medicare plan we offer. However, dependent coverage will end if your
coverage ends under the Medicare plan.
What happens to your dependents if you die?
Coverage for dependents may continue for some time after your death. See the Special coverage options after
your coverage ends section for more information.
Why would we end your coverage?
We may immediately end your coverage if you commit fraud or you intentionally misrepresented yourself when
you applied for or obtained coverage. You can refer to the General provisions – other things you should know
section for more information on rescissions.
On the date your coverage ends, we will refund to your employer any prepayment for periods after the date
your coverage ended.
Special coverage options after your coverage ends
When coverage m ay continue under the p lan
This section explains options you may have after your coverage ends under this plan. Your individual situation
will determine what options you will have. Contact the policyholder to see what options apply to you.
In some cases, premium payment is required for coverage to continue. Your coverage will continue under the
plan as long as the policyholder and we have agreed to do so. It is the policyholder responsibility to let us know
when your work ends. If the policyholder and we agree in writing, we will extend the limits.
Consolidated Omnibus Budget Reconciliation Act (COBRA) Rights
What are your COBRA rights?
The federal COBRA law usually applies to employers of group sizes of 20 or more and gives employees and their
covered dependents the right to keep their health coverage for 18, 29 or 36 months after a qualifying event. The
qualifying event is something that happens that results in you losing your coverage.
The qualifying events are:
• Your active employment ends for reasons other than gross misconduct
• Your working hours are reduced
• You divorce or legally separate and are no longer responsible for dependent coverage
• You become entitled to benefits under Medicare
• Your covered dependent children no longer qualify as dependents under the plan
• You die
• You are a retiree eligible for retiree health coverage and your former employer files for bankruptcy
AL HCOC 08 as amended by 55
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Talk with your employer if you have questions about COBRA or to enroll.
Continuation of coverage f or ot her reasons
How you can extend coverage if you are totally disabled when coverage ends
Your coverage may be extended if you are totally disabled when coverage ends.
You are “totally disabled” if you cannot work at your occupation or any other occupation for pay or profit.
Your dependent is “totally disabled” if that person cannot engage in most normal activities of a healthy person
of the same age and gender.
You may extend coverage until the earliest of:
• When you or your dependents are no longer totally disabled
• When you become covered by another health benefits plan
• 12 months of coverage
How you can extend coverage for your disabled child beyond the plan age limits
You have the right to extend coverage for your dependent child beyond plan age limits, if the child is not able to
be self-supporting because of mental or physical disability and depends mainly (more than 50% of their income)
on you for support.
The right to coverage will continue only as long as a physician certifies that your child still is disabled.
We may ask you to send us proof of the disability within 90 days of the date coverage would have ended. Before
we extend coverage, we may ask that your child get a physical exam. We will pay for that exam.
We may ask you to send proof that your child is disabled after coverage is extended. We won’t ask for this proof
more than once a year. You must send it to us within 31 days of our request. If you don’t, we can terminate
coverage for your dependent child.
How you can extend coverage w hen getting inpatient care w hen coverage e nds
Your coverage may be extended if you are getting inpatient care in a hospital or skilled nursing facility when
coverage ends.
Benefits are extended for the condition that caused the hospital or skilled nursing facility stay or for
complications from the condition. Benefits aren’t extended for other medical conditions.
You can continue to get care for this condition until the earliest of:
• When you are discharged
• When you no longer need inpatient care
• When you become covered by another health benefits plan
• 12 months of coverage
AL HCOC 08 as amended by 56
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
How you can extend coverage for hearing services and supplies when coverage ends
If you are not totally disabled when your coverage ends, coverage for hearing services and supplies may be
extended for 30 days after your coverage ends:
• If the prescription for the hearing aid is written during the 30 days before your coverage ends
• If the hearing aid is ordered during the 30 days before your coverage ends
How you can extend coverage for your child in college on medical leave
You have the right to extend coverage for your dependent college student who takes a medically necessary
leave of absence from school. The right to coverage will be extended until the earlier of:
• One year after the leave of absence begins, or
• The date coverage would otherwise end.
To extend coverage the leave of absence must:
• Begin while the dependent child is suffering from a serious illness or injury,
• Cause the dependent child to lose status as a full-time student under the plan
• Be certified by the treating physician as medically necessary due to serious illness or injury. The
physician treating your child will be asked to keep us informed of any changes.
AL HCOC 08 as amended by 57
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
General provisions – other things you should know
Administrative provisions
How you and we will interpret this certificate
We prepared this certificate according to ERISA and other federal and state laws that apply. You and we will
interpret it according to these laws. Also, you are bound by our interpretation of this certificate when we
administer your coverage.
How we administer this plan
We apply policies and procedures we’ve developed to administer this plan.
Who’s responsible to you
We are responsible to you for what our employees and other agents do.
We are not responsible for what is done by your providers. Even network providers are not our employees or
agents.
Coverage and services
Your coverage can change
Your coverage is defined by the group policy. This document may have amendments and riders too. Under
certain circumstances, we, the policyholder or the law may change your plan. When an emergency or epidemic
is declared, we may modify or waive precertification, prescription quantity limits or your cost share if you are
affected. Only we may waive a requirement of your plan. No other person, including the policyholder or
provider, can do this.
Legal action
You must complete the internal appeal process before you take any legal action against us for any expense or
bill. See the Complaints, claim decisions and appeal procedures section. You cannot take any action until 60 days
after we receive written submission of a claim.
No legal action can be brought to recover payment under any benefit after 3 years from the deadline for filing
claims.
Physical examination and evaluations
At our expense, we have the right to have a physician of our choice examine you. This will be done at
reasonable times while certification or a claim for benefits is pending or under review.
Records of expenses
You should keep complete records of your expenses. They may be needed for a claim. Important things to keep
are:
• Names of physicians and others who furnish services
• Dates expenses are incurred
• Copies of all bills and receipts
AL HCOC 08 as amended by 58
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Honest mistakes and intentional deception
Honest mistakes
You or the policyholder may make an honest mistake when you share facts with us. When we learn of the
mistake, we may make a fair change in premium contribution or in your coverage. If we do, we will tell you what
the mistake was. We won’t make a change if the mistake happened more than 2 years before we learned of it.
Intentional deception
If we learn that you defrauded us or you intentionally misrepresented material facts, we can take actions that
can have serious consequences for your coverage. These serious consequences include, but are not limited to:
• Loss of coverage, starting at some time in the past
• Loss of coverage going forward
• Denial of benefits
• Recovery of amounts we already paid
We also may report fraud to criminal authorities.
Rescission means you lose coverage both going forward and going backward. If we paid claims for your past
coverage, we will want the money back.
You have special rights if we rescind your coverage:
• We will give you 60 days advance written notice of any rescission of coverage
• You have the right to an Aetna appeal
• You have the right to a third party review conducted by an independent ERO
Some other money issues
Assignment of benefits
When you see a network provider, they will usually bill us directly. When you see an out-of-network provider,
we may choose to pay you or to pay the provider directly. To the extent allowed by law, we will not accept an
assignment to an out-of-network provider.
Financial sanctions exclusions
If coverage provided under this certificate violates or will violate any economic or trade sanctions, the coverage
will be invalid immediately. For example, we cannot pay for covered services if it violates a financial sanction
regulation. This includes sanctions related to a person or a country under sanction by the United States, unless it
is allowed under a written license from the Office of Foreign Asset Control (OFAC). You can find out more by
visiting https://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.
Premium contribution
Your plan requires that the policyholder make premium contribution payments. We will not pay for benefits if
premium contributions are not made. Any decision to not pay benefits can be appealed.
Recovery of overpayments
We sometimes pay too much for covered services or pay for something that this plan doesn’t cover. If we do,
we can require the person we paid, you or your provider, to return what we paid. If we don’t do that, we have
the right to reduce any future benefit payments by the amount we paid by mistake.
AL HCOC 08 as amended by 59
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
When you are injured
If someone else caused you to need care – say, a careless driver who injured you in a car crash – you may have a
right to get money. We are entitled to that money, up to the amount we pay for your care. We have that right
no matter whom the money comes from – for example, the other driver, the policyholder, or another insurance
company.
To help us get paid back, you are doing these things now:
• Agreeing to repay us from money you receive because of your injury.
• Agreeing to cooperate with us so we can get paid back in full. For example, you’ll tell us within 30 days
of when you seek money for your injury or illness. You’ll hold any money you receive until we are repaid.
And you’ll give us the right to money you get, ahead of everyone else.
• Agreeing to provide us notice of any money you will be receiving before pay out, or within 5 days of
when you receive the money.
We don’t have to reduce the amount we’re due for any reason, even to help pay your lawyer or pay other costs
you incurred to get a recovery.
Your health information
We will protect your health information. We will only use or share it with others as needed for your care and
treatment. We will also use and share it to help us process your claims and manage your plan.
You can get a free copy of our Notice of Privacy Practices. Just contact us.
When you accept coverage under this plan, you agree to let your providers share information with us. We need
information about your physical and mental condition and care.
Effect of benefits under other plans
Health Maintenance Organization (HMO) plan
If you are eligible for and enrolled in coverage under an HMO plan offered by the policyholder, you will not have
coverage under this plan on the date that your HMO plan coverage starts. If you are pregnant when you change
plans, you may be eligible for an extension of benefits. Contact us for more information.
AL HCOC 08 as amended by 60
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Glossary
Allowable amount
See How your plan works – What the plan pays and what you pay.
Behavioral health provider
A health professional who is licensed or certified to provide covered services for mental health and substance
related disorders in the state where the person practices.
Brand-name prescription drug
An FDA-approved drug marketed with a specific name or trademark name by the company that manufactures it;
often the same company that developed and patents it.
Coinsurance
A percentage paid by a covered person for a covered service.
Copay, copayment
A dollar amount or percentage paid by a covered person for a covered service.
Covered service
The benefits, subject to varying cost shares, covered in this plan. These are:
• Described in the Providing covered services section
• Not listed as an exclusion in the Coverage and exclusions – Providing covered services section or the
General plan exclusions section
• Not beyond any limits in the schedule of benefits
• Medically necessary. See the How your plan works – Medical necessity and precertification requirements
section and the Glossary for more information
Deductible
The amount a covered person pays for covered services per year before we start to pay.
Detoxification
The process of getting alcohol or other drugs out of an addicted person’s system and getting them physically
stable.
Drug guide
A list of prescription and OTC drugs and devices established by us or an affiliate. It does not include all
prescription and OTC drugs and devices. This list can be reviewed and changed by us or an affiliate. A copy is
available at your request. Go to https://www.aetna.com/individuals-families/find-a-medication.html.
AL HCOC 08 as amended by 61
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Emergency medical condition
An acute, severe medical condition that:
• Needs immediate medical care
• Leads a person with average knowledge of health and medicine to believe that, without immediate
medical care, it could result in:
- Danger to life or health
- Loss of a bodily function
- Loss of function to a body part or organ
- Danger to the health of an unborn baby
Emergency services
Treatment given in a hospital’s emergency room or an independent freestanding emergency department. This
includes evaluation of and treatment to stabilize the emergency medical condition. An independent
freestanding emergency department means a health care facility that is geographically separate, distinct, and
licensed separately from a hospital and provides emergency services.
Experimental or investigational
Drugs, treatments or tests not yet accepted by physicians or by insurance plans as standard treatment. They
may not be proven as effective or safe for most people.
A drug, device, procedure, or treatment is experimental or investigational if:
• There is not enough outcome data available from controlled clinical trials published in the peer-
reviewed literature to validate its safety and effectiveness for the illness or injury involved.
• The needed approval by the FDA has not been given for marketing.
• A national medical or dental society or regulatory agency has stated in writing that it is experimental or
investigational or suitable mainly for research purposes.
• It is the subject of a Phase I, Phase II or the experimental or research arm of a Phase III clinical trial.
These terms have the meanings given by regulations and other official actions and publications of the
FDA and Department of Health and Human Services.
• Written protocols or a written consent form used by a facility provider state that it is experimental or
investigational.
Formulary exclusions list
A list of prescription drugs not covered under the plan. This list is subject to change.
Generic prescription drug
An FDA-approved drug with the same intended use as the brand-name product, that is considered to be as
effective as the brand-name product. It offers the same:
• Dosage
• Safety
• Strength
• Quality
• Performance
AL HCOC 08 as amended by 62
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
AL HCOC 08 as amended by 63
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Health professional
A person who is authorized by law to provide health care services to the public; for example, physicians, nurses
and physical therapists.
Home health care agency
An agency authorized by law to provide home health services, such as skilled nursing and other therapeutic
services.
Hospital
An institution licensed as a hospital by applicable law and accredited by The Joint Commission (TJC). This is a
place that offers medical care. Patients can stay overnight for care. Or they can be treated and leave the same
day. All hospitals must meet set standards of care. They can offer general or acute care. They can also offer
service in one area, like rehabilitation.
Infertility
A disease defined by the failure to become pregnant:
• For a female with a male partner, after:
- 1 year of frequent, unprotected heterosexual sexual intercourse if under the age of 35
- 6 months of frequent, unprotected heterosexual sexual intercourse if age 35 or older
• For a female without a male partner, after:
• At least 12 cycles of donor insemination if under the age of 35
• 6 cycles of donor insemination if age 35 or older
• For a male without a female partner, after:
- At least 2 abnormal semen analyses obtained at least 2 weeks apart
• For an individual or their partner who has been clinically diagnosed with gender dysphoria
Jaw joint d isorder
This is:
• A temporomandibular joint (TMJ) dysfunction or any similar disorder of the jaw joint
• A myofascial pain dysfunction (MPD) of the jaw
• Any similar disorder in the relationship between the jaw joint and the related muscles and nerves
Mail order pharmacy
A pharmacy where prescription drugs are legally dispensed by mail or other carrier.
Maximum out-of-pocket limit
The maximum out-of-pocket limit is the most a covered person will pay per year in copayments, coinsurance
and deductible, if any, for covered services.
Medically necessary, medical necessity
Health care services or supplies that prevent, evaluate, diagnose or treat an illness, injury, disease or its
symptoms, and that are all of the following, as determined by us within our discretion:
• In accordance with “generally accepted standards of medical practice”
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for
your illness, injury or disease
• Not primarily for your convenience, the convenience of your physician, or other health care provider
• 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 your illness, injury or
disease
Generally accepted standards of medical practice mean:
• Standards that are based on credible scientific evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community and
• Following the standards set forth in our clinical policies and applying clinical judgment
Important note:
We develop and maintain clinical policy bulletins that describe the generally accepted standards of medical
practice, credible scientific evidence, and prevailing clinical guidelines that support our decisions regarding
specific services. We use these bulletins and other resources to help guide individualized coverage decisions
under our plans and to determine whether an intervention is experimental or investigational. They are subject
to change. You can find these bulletins and other information at https://www.aetna.com/health-care-
professionals/clinical-policy-bulletins.html. You can also contact us. See the Contact us section for how.
Mental health disorder
A mental health disorder is in general, a set of symptoms or behavior associated with distress and interference
with personal function. A complete definition of mental health disorder is in the most recent edition of
Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association.
Negotiated charge
See How your plan works – What the plan pays and what you pay.
Network provider
A provider listed in the directory for your plan. A NAP provider listed in the NAP directory is not a network
provider. A network provider can also be referred to as an in-network provider.
Other health care
Other health care coverage is care you get from an out-of-network provider when you could not reasonably get
services and supplies from an in-network provider.
Out-of-network provider
A provider who is not a network provider.
Physician
A health professional trained and licensed to practice and prescribe medicine under the laws of the state where
they practice; specifically, doctors of medicine or osteopathy. Under some plans, a physician can also be a
primary care physician (PCP).
Precertification, precertify
Pre-approval that you or your provider receives from us before you receive certain covered services. This may
include a determination by us as to whether the service is medically necessary and eligible for coverage.
AL HCOC 08 as amended by 64
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Preferred drug
A prescription drug or device that may have a lower out-of-pocket cost than a non-preferred drug.
Prescription
This is an instruction written by a physician or other provider that authorizes a patient to receive a service,
supply, medicine or treatment.
Primary care physician (PCP)
A physician who:
• The directory lists as a PCP
• Is selected by a covered person from the list of PCPs in the directory
• Supervises, coordinates and provides initial care and basic medical services to a covered person
• Shows in our records as your PCP
A PCP can be any of the following providers:
• General practitioner
• Family physician
• Internist
• Pediatrician
• OB, GYN, and OB/GYN
• Medical group (primary care office)
Provider
A physician, pharmacist, health professional, person, or facility, licensed or certified by law to provide health
care services to you. If state law does not specifically provide for licensure or certification, they must meet all
Medicare approval standards even if they don’t participate in Medicare.
Psychiatric hospital
An institution licensed or certified as a psychiatric hospital by applicable laws to provide a program for the
diagnosis, evaluation, and treatment of alcoholism, drug abuse or mental disorders (including substance related
disorders).
Residential treatment facility
An institution specifically licensed as a residential treatment facility by applicable laws to provide for mental
health or substance related disorder residential treatment programs. It is credentialed by us or is accredited by
one of the following agencies, commissions or committees for the services being provided:
• The Joint Commission (TJC)
• The Committee on Accreditation of Rehabilitation Facilities (CARF)
• The American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP)
• The Council on Accreditation (COA)
In addition to the above requirements, an institution must meet the following:
For residential treatment programs treating mental disorders:
• A behavioral health provider must be actively on duty 24 hours/day for 7 days/week
• The patient must be treated by a psychiatrist at least once per week
AL HCOC 08 as amended by 65
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
• The medical director must be a psychiatrist
• It is not a wilderness treatment program (whether or not the program is part of a licensed residential
treatment facility or otherwise licensed institution)
For substance related residential treatment programs:
• A behavioral health provider or an appropriately state certified professional (CADC, CAC, etc.) must be
actively on duty during the day and evening therapeutic programming
• The medical director must be a physician
• It is not a wilderness treatment program (whether or not the program is part of a licensed residential
treatment facility or otherwise licensed institution)
For detoxification programs within a residential setting:
• An R.N. must be onsite 24 hours/day for 7 days/week within a residential setting
• Residential care must be provided under the direct supervision of a physician
Retail pharmacy
A community pharmacy that dispenses outpatient prescription drugs.
Room and board
A facility’s charge for your overnight stay and other services and supplies expressed as a daily or weekly rate.
Semi-private room rate
An institution’s room and board charge for most beds in rooms with 2 or more beds. If there are no such rooms,
we will calculate the rate based on the rate most commonly charged by similar institutions in the same
geographic area.
Skilled nursing facility
A facility specifically licensed as a skilled nursing facility by applicable laws to provide skilled nursing care.
Skilled nursing facilities also include:
• Rehabilitation hospitals
• Portions of a rehabilitation hospital
• A hospital designated for skilled or rehabilitation services
Skilled nursing facility does not include institutions that provide only:
• Minimal care
• Custodial care
• Ambulatory care
• Part-time care
It does not include institutions that primarily provide for the care and treatment of mental disorders or
substance related disorders.
Skilled nursing services
Services provided by a registered nurse or licensed practical nurse within the scope of their license.
AL HCOC 08 as amended by 66
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Specialist
A physician who practices in any generally accepted medical or surgical sub-specialty.
Specialty prescription drug
An FDA-approved prescription drug that typically has a higher cost and requires special handling, special storage
or monitoring. These drugs may be administered:
• Orally (mouth)
• Topically (skin)
• By inhalation (mouth or nose)
• By injection (needle)
Specialty pharmacy
A pharmacy that fills prescriptions for specialty drugs.
Stay
A full-time inpatient confinement for which a room and board charge is made.
Step therapy
A form of precertification under which certain prescription drugs are excluded from coverage, unless a first-line
therapy drug is used first by you. The list of step therapy drugs is subject to change by us or an affiliate. An
updated copy of the list of drugs subject to step therapy is available upon request or on our website at
https://www.aetna.com/individuals-families/find-a-medication.html.
Substance related disorder
A substance related disorder, addictive disorder, or both, as defined in the Diagnostic and Statistical Manual of
Mental Disorders (DSM) published by the American Psychiatric Association.
Surgery, surgical procedure
The diagnosis and treatment of injury, deformity and disease by manual and instrumental means, such as:
• Cutting
• Abrading
• Suturing
• Destruction
• Ablation
• Removal
• Lasering
• Introduction of a catheter (e.g., heart or bladder catheterization) or scope (e.g., colonoscopy or other
types of endoscopy)
• Correction of fracture
• Reduction of dislocation
• Application of plaster casts
• Injection into a joint
• Injection of sclerosing solution
• Otherwise physically changing body tissues and organs
AL HCOC 08 as amended by 67
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
Telemedicine
A consultation between you and a physician, specialist, or behavioral health provider, or telemedicine provider
who is performing a clinical medical or behavioral health service by means of electronic communication.
Terminal illness
A medical prognosis that you are not likely to live more than 12 months.
Urgent co ndition
An illness or injury that requires prompt medical attention but is not a life-threatening emergency medical
condition.
Walk-in clinic
A health care facility that provides limited medical care on a scheduled and unscheduled basis. A walk-in clinic
may be located in, near or within a:
• Drug store
• Pharmacy
• Retail store
• Supermarket
The following are not considered a walk-in clinic:
• Ambulatory surgical center
• Emergency room
• Hospital
• Outpatient department of a hospital
• Physician’s office
• Urgent care facility
AL HCOC 08 as amended by
AL COCAmend-2021 01, AL COCAmendAdmin-2021 01,
AL COCAmendRX-2021 01, AL COCAmend-2022 01,
AL COCAmend-Telemed-2022 01, AL COCAmend-2023 01,
AL COCFedAmend-2023 01
68
Additional Information Provided by
SAMPLE CO, INC.
The following information is provided to you in accordance with the Employee Retirement Income Security Act
of 1974 (ERISA). It is not a part of your booklet-certificate. Your Plan Administrator has determined that this
information together with the information contained in your booklet-certificate is the Summary Plan Description
required by ERISA.
In furnishing this information, Aetna is acting on behalf of your Plan Administrator who remains responsible for
complying with the ERISA reporting rules and regulations on a timely and accurate basis.
Name of Plan:
SAMPLE CO, INC.
Employer Identification Number:
SAMPLE
Plan Number:
SAMPLE
Type of Plan:
SAMPLE
Type of Administration:
Group Insurance Policy with:
Aetna Life Insurance Company
151 Farmington Avenue
Hartford, CT 06156
Plan Administrator:
SAMPLE
SAMPLE
SAMPLE
Telephone Number: SAMPLE
Agent For Service of Legal Process:
SAMPLE
SAMPLE
SAMPLE
Service of legal process may also be made upon the Plan Administrator
End of Plan Year:
SAMPLE
Source of Contributions:
SAMPLE
Procedure for Amending the Plan:
The Employer may amend the Plan from time to time by a written instrument signed by SAMPLE.
ERISA Rights
As a participant in the group insurance plan you are entitled to certain rights and protections under the
Employee Retirement Income Security Act of 1974. ERISA provides that all plan participants shall be entitled to:
Receive Information about Your Plan and Benefits
Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites
and union halls, all documents governing the Plan, including insurance contracts, collective bargaining
agreements, and a copy of the latest annual report (Form 5500 Series) that is filed by the Plan with the U.S.
Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security
Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the
Plan, including insurance contracts, collective bargaining agreements, and copies of the latest annual report
(Form 5500 Series), and an updated Summary Plan Description. The Administrator may make a reasonable
charge for the copies.
Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish
each participant with a copy of this summary annual report.
Receive a copy of the procedures used by the Plan for determining a qualified domestic relations order (QDRO)
or a qualified medical child support order (QMCSO).
Continue Group Health Plan Coverage
Continue health care coverage for yourself, your spouse, or your dependents if there is a loss of coverage under
the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review
this summary plan description and the documents governing the Plan for the rules governing your COBRA
continuation coverage rights.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the employee benefit plan. The people who operate your Plan, called “fiduciaries” of the
Plan, have a duty to do so prudently and in your interest and that of other plan participants and beneficiaries.
No one, including your employer, your union, or any other person, may fire you or otherwise discriminate
against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this
was done, to obtain documents relating to the decision without charge, and to appeal any denial, all within
certain time schedules.
Under ERISA there are steps you can take to enforce the above rights. For instance, if you request materials
from the Plan and do not receive them within 30 days you may file suit in a federal court. In such a case, the
court may require the Plan Administrator to provide the materials and pay up to $ 110 a day until you receive
the materials, unless the materials were not sent because of reasons beyond the control of the Administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or
federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the status of a
domestic relations order or a medical child support order, you may file suit in a federal court.
If it should happen that plan fiduciaries misuse the Plan's money or if you are discriminated against for asserting
your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in a federal court.
The court will decide who should pay court costs and legal fees. If you are successful, the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and
fees, for example, if it finds your claim is frivolous.
Assistance with Your Questions
If you have any questions about your Plan, you should contact the Plan Administrator.
If you have any questions about this statement or about your rights under ERISA, you should contact:
▪ the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your
telephone directory; or
▪ the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S.
Department of Labor, 200 Constitution Avenue, N.W., Washington D.C. 20210.
You may also obtain certain publications about your rights and responsibilities under ERISA by calling the
publications hotline of the Employee Benefits Security Administration.
Statement of Rights under the Newborns' and Mothers' Health Protection Act
Under federal law, group health plans and health insurance issuers offering group health insurance coverage
generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or
newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by
cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your
physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or
newborn earlier.
Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any
later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn
than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that you, your physician, or other health care
provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, you may
be required to obtain precertification for any days of confinement that exceed 48 hours (or 96 hours). For
information on precertification, contact your plan administrator.
Notice Regarding Women's Health and Cancer Rights Act
Under this health plan, as required by the Women's Health and Cancer Rights Act of 1998, coverage will be
provided to a person who is receiving benefits in connection with a mastectomy and who elects breast
reconstruction in connection with the mastectomy for:
(1) all stages of reconstruction of the breast on which a mastectomy has been performed;
(2) surgery and reconstruction of the other breast to produce a symmetrical appearance;
(3) prostheses; and
(4) treatment of physical complications of all stages of mastectomy, including lymphedemas.
This coverage will be provided in consultation with the attending physician and the patient, and will be provided
in accordance with the plan design, limitations, copays, deductibles, and referral requirements, if any, as
outlined in your plan documents.
If you have any questions about our coverage of mastectomies and reconstructive surgery, please contact the
Member Services number on your ID card.
For more information, you can visit this U.S. Department of Health and Human Services website,
http://www.cms.gov/home/regsguidance.asp, and this U.S. Department of Labor website,
https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans.
IMPORTANT HEALTH CARE REFORM NOTICES
CHOICE OF PROVIDER
If your Aetna plan generally requires or allows the designation of a primary care provider, you have the right to
designate any primary care provider who participates in our network and who is available to accept you or your
family members. If the plan or health insurance coverage designates a primary care provider automatically,
then until you make this designation, Aetna designates one for you. For information on how to select a primary
care provider, and for a list of the participating primary care providers, contact your Employer or, if you are a
current member, your Aetna contact number on the back of your ID card.
If your Aetna plan allows for the designation of a primary care provider for a child, you may designate a
pediatrician as the primary care provider.
If your Aetna plan provides coverage for obstetric or gynecological care and requires the designation of a
primary care provider then you do not need prior authorization from Aetna or from any other person (including
a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care
professional in our network who specializes in obstetrics or gynecology. The health care professional, however,
may be required to comply with certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health
care professionals who specialize in obstetrics or gynecology, contact your Employer or, if you are a current
member, your Aetna contact number on the back of your ID card.
Confidentiality Notice
Aetna considers personal information to be confidential and has policies and procedures in place to protect it
against unlawful use and disclosure. By "personal information," we mean information that relates to a member's
physical or mental health or condition, the provision of health care to the member, or payment for the provision
of health care or disability or life benefits to the member. Personal information does not include publicly
available information or information that is available or reported in a summarized or aggregate fashion but does
not identify the member.
When necessary or appropriate for your care or treatment, the operation of our health, disability or life
insurance plans, or other related activities, we use personal information internally, share it with our affiliates,
and disclose it to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers), payors
(health care provider organizations, employers who sponsor self-funded health plans or who share responsibility
for the payment of benefits, and others who may be financially responsible for payment for the services or
benefits you receive under your plan), other insurers, third party administrators, vendors, consultants,
government authorities, and their respective agents. These parties are required to keep personal information
confidential as provided by applicable law. In our health plans, participating network providers are also required
to give you access to your medical records within a reasonable amount of time after you make a request.
Some of the ways in which personal information is used include claim payment; utilization review and
management; medical necessity reviews; coordination of care and benefits; preventive health, early detection,
vocational rehabilitation and disease and case management; quality assessment and improvement activities;
auditing and anti-fraud activities; performance measurement and outcomes assessment; health, disability and
life claims analysis and reporting; health services, disability and life research; data and information systems
management; compliance with legal and regulatory requirements; formulary management; litigation
proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators;
underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our
business. We consider these activities key for the operation of our health, disability and life plans. To the extent
permitted by law, we use and disclose personal information as provided above without member consent.
However, we recognize that many members do not want to receive unsolicited marketing materials unrelated to
their health, disability and life benefits. We do not disclose personal information for these marketing purposes
unless the member consents. We also have policies addressing circumstances in which members are unable to
give consent.
To obtain a copy of our Notice of Privacy Practices, which describes in greater detail our practices concerning
use and disclosure of personal information, please call the toll-free Member Services number on your ID card or
visit our Internet site at www.aetna.com.
Continuation of Coverage During an Approved Leave of Absence Granted to Comply With Federal
Law
This continuation of coverage section applies only for the period of any approved family or medical leave
(approved FMLA leave) required by Family and Medical Leave Act of 1993 (FMLA). If your Employer grants you
an approved FMLA leave for a period in excess of the period required by FMLA, any continuation of coverage
during that excess period will be subject to prior written agreement between Aetna and your Employer.
If your Employer grants you an approved FMLA leave in accordance with FMLA, you may, during the continuance
of such approved FMLA leave, continue Health Expense Benefits for you and your eligible dependents.
At the time you request the leave, you must agree to make any contributions required by your Employer to
continue coverage. Your Employer must continue to make premium payments.
If Health Expense Benefits has reduction rules applicable by reason of age or retirement, Health Expense
Benefits will be subject to such rules while you are on FMLA leave.
Coverage will not be continued beyond the first to occur of:
▪
The date you are required to make any contribution and you fail to do so.
▪ The date your Employer determines your approved FMLA leave is terminated.
▪ The date the coverage involved discontinues as to your eligible class. However, coverage for health expenses
may be available to you under another plan sponsored by your Employer.
Any coverage being continued for a dependent will not be continued beyond the date it would otherwise
terminate.
If Health Expense Benefits terminate because your approved FMLA leave is deemed terminated by your
Employer, you may, on the date of such termination, be eligible for Continuation Under Federal Law on the
same terms as though your employment terminated, other than for gross misconduct, on such date. If the group
contract provides any other continuation of coverage (for example, upon termination of employment, death,
divorce or ceasing to be a defined dependent), you (or your eligible dependents) may be eligible for such
continuation on the date your Employer determines your approved FMLA leave is terminated or the date of the
event for which the continuation is available.
If you acquire a new dependent while your coverage is continued during an approved FMLA leave, the
dependent will be eligible for the continued coverage on the same terms as would be applicable if you were
actively at work, not on an approved FMLA leave.
If you return to work for your Employer following the date your Employer determines the approved FMLA leave
is terminated, your coverage under the group contract will be in force as though you had continued in active
employment rather than going on an approved FMLA leave provided you make request for such coverage within
31 days of the date your Employer determines the approved FMLA leave to be terminated. If you do not make
such request within 31 days, coverage will again be effective under the group contract only if and when Aetna
gives its written consent.
If any coverage being continued terminates because your Employer determines the approved FMLA leave is
terminated, any Conversion Privilege will be available on the same terms as though your employment had
terminated on the date your Employer determines the approved FMLA leave is terminated.
75
Schedule of benefits
If this is an ERISA plan, you may have certain rights under this plan. ERISA may not apply
to a church or government group. Please contact the policyholder for additional
information.
Prepared for:
Policyholder: SAMPLE
Policyholder number: GP- SAMPLE
Group policy effective date: SAMPLE
Plan name: SAMPLE, Schedule of Benefits: XX
Plan effective date: SAMPLE
Plan issue date: SAMPLE
Underwritten by Aetna Life Insurance Company in the state of SAMPLE
76
Schedule of benefits
This schedule of benefits (schedule) lists the deductibles, copayments or coinsurance, if any apply to the
covered services you receive under the plan. You should review this schedule to become aware of these and any
limits that apply to these services.
How your cost share works
• The deductibles and copayments, if any, listed in the schedule below are the amounts that you pay for
covered services.
- For the covered services under your medical plan, you will be responsible for the dollar amount
- For pharmacy benefits where a percentage cost share acts like a copayment, you will be responsible
for the percentage amount
• Coinsurance amounts, if any, listed in the schedule below are what the plan will pay for covered
services.
• Sometimes your cost share shows a combination of your dollar amount copayment that you will be
responsible for and the coinsurance percentage that your plan will pay.
• You are responsible to pay any deductibles, copayments and remaining coinsurance, if they apply and
before the plan will pay for any covered services.
• Other health care coverage is care you get from an out-of-network provider when you could not
reasonably get services and supplies from an in-network provider.
• This plan doesn’t cover every health care service. You pay the full amount of any health care service you
get that is not a covered service.
• This plan has limits for some covered services. For example, these could be visit, day or dollar limits.
They may be:
- Combined limits between in-network and out-of-network providers
- Separate limits for in-network and out-of-network providers
- Based on a rolling, 12-month period starting with the date of your most recent visit under this plan
See the schedule for more information about limits.
• Your cost share may vary if the covered service is preventive or not. Ask your physician or contact us if
you have a question about what your cost share will be.
For examples of how cost share and deductible work, go to the Using your Aetna benefits section under
Individuals & Families at https://www.aetna.com/.
Important note:
Covered services are subject to the Calendar Year deductible, maximum out-of-pocket, limits, copayment
or coinsurance unless otherwise stated in this schedule. The Surprise bill section in the certificate explains
your protections from a surprise bill.
Under this plan, you will:
1. Pay your copayment
2. Then pay any remaining deductible
3. Then pay your coinsurance
Your copayment does not apply to any deductible.
77
78
How your deductible works
The deductible is the amount you pay for covered services each year before the plan starts to pay. This is in
addition to any copayment or coinsurance you pay when you get covered services from an in-network or out-
of-network provider. This schedule shows the deductible amounts that apply to your plan. Once you have met
your deductible, we will start sharing the cost when you get covered services. You will continue to pay
copayments or coinsurance, if any, for covered services after you meet your deductible.
How your PCP or ph ysician office visit cos t sh are works
You will pay the PCP cost share when you get covered services from any PCP.
How your maximum out-of-pocket w orks
This schedule shows the maximum out-of-pocket limits that apply to your plan. Once you reach your maximum
out-of-pocket limit, your plan will pay for covered services for the remainder of that year.
Contact us
We are here to answer questions. See the Contact us section in your certificate.
Aetna Life Insurance Company’s group policy provides the coverage described in this schedule of benefits. This
schedule replaces any schedule of benefits previously in use. Keep it with your certificate.
Plan features
Precertification covered services reduction
This only applies to out-of-network covered services:
Your certificate contains a complete description of the precertification process. You will find details in the How
your plan works - Medical necessity and precertification requirements section.
If precertification for covered services isn’t completed, when required, it results in the following benefit
reduction:
• A $XX benefit reduction applied separately to each type of covered service
You may have to pay an additional portion of the allowable amount because you didn’t get precertification.
This portion is not a covered service and doesn’t apply to your deductible or maximum out-of-pocket limit, if
you have one.
Deductible
You have to meet your deductible before this plan pays for benefits.
Deductible type
In-network
Out-of-network
Other health care
Individual
$XX per year
$XX per year
$XX per year
Family
$XX per year
$XX per year
$XX per year
Deductible waiver
There is no in-network deductible for the following covered services:
• Preventive care
• Family planning services – female contraceptives
Deductible waiver provisions for child health supervision services
The deductible is waived for child health supervision services through age 5.
79
Outpatient pr escription drug deductible waiver
There is no outpatient prescription drug deductible for non-preferred, preferred, brand-name, value, preferred
generic, generic prescription drugs filled at a retail and mail-order pharmacy.
Deductible and cost sh are waiver for risk reducing breast cancer prescription drugs
The prescription drug deductible and per prescription cost share will not apply to risk reducing breast cancer
prescription drugs when obtained at a network pharmacy. This means they will be paid at 100%.
Deductible and cost sh are waiver for contraceptives (birth control)
The prescription drug deductible and per prescription cost share will not apply to female contraceptive
methods when obtained at a network pharmacy. This means they will be paid at 100%. This includes certain OTC
and generic contraceptive prescription drugs and devices for each of the methods identified by the FDA. If a
generic prescription drug is not available, the brand-name prescription drug for that method will be paid at
100%.
The prescription drug deductible and cost share will apply to prescription drugs that have a generic equivalent
or alternative available within the same therapeutic drug class obtained at a network pharmacy unless we
approve a medical exception. A therapeutic drug class is a group of drugs or medications that have a similar or
identical mode of action or are used for the treatment of the same or similar disease or injury.
Deductible and cost sh are waiver for tobacco cessation prescription and OTC drugs
The prescription drug deductible and the per prescription cost share will not apply to the first two 90-day
treatment programs for tobacco cessation prescription and OTC drugs when obtained at a network retail
pharmacy. This means they will be paid at 100%. Your per prescription cost share will apply after those two
programs have been exhausted.
Per admission copayment
Per admission
copayment type
In-network
Out-of-network
Other health care
Per admission
copayment
$XX per admission
Not applicable
Not applicable
Per admission deductible
Per admission
deductible type
In-network
Out-of-network
Other health care
Per admission
deductible
Not applicable
Not applicable
$XX per admission
Maximum out-of-pocket limit
Includes the deductible.
Maximum out-of-
pocket type
In-network
Out-of-network
Other health care
Individual
$XX per year
$XX per year
$XX per year
Family
$XX per year
$XX per year
$XX per year
80
General coverage provisions
This section explains the deductible, maximum out-of-pocket limit and limitations listed in this schedule.
Deductible provisions
Covered services that are subject to the deductible include those provided under the medical plan and the
prescription drug plan.
In-network covered services will apply only to the in-network deductible. Out-of-network covered services will
apply only to the out-of-network deductible.
The deductible may not apply to some covered services. You still pay the copayment or coinsurance, if any, for
these covered services.
Individual deductible
You pay for covered services each year before the plan begins to pay. This individual deductible applies
separately to you and each covered dependent. After the amount paid reaches the individual deductible, this
plan starts to pay for covered services for the rest of the year.
Family deductible
You pay for covered services each year before the plan begins to pay. After the amount paid for covered
services reaches this family deductible, this plan starts to pay for covered services for the rest of the year. To
satisfy this family deductible for the rest of the year, the combined covered services that you and each of your
covered dependents incur toward the individual deductible must reach this family deductible in a year. When
this happens in a year, the individual deductibles for you and your covered dependents are met for the rest of
the year.
Deductible credit
If you paid part or all of your deductible under other coverage for the year that this plan went into effect, we
will deduct the amount paid under the other coverage from the deductible on this plan for the same year. If we
ask, you must submit a detailed explanation of benefits (EOB) showing the dates and amount of the deductible
met from the other coverage in order to receive the credit.
Deductible carryover
Any amounts that you paid for covered services in the last 90 days of a year that apply toward that year’s
deductible will also count toward the following year’s deductible.
Copayment
This is the dollar amount you pay for covered services. In most plans, you pay this after you meet your
deductible limit. In prescription drug plans, it is the amount you pay for covered drugs.
Per admission copayment
This is the amount you are required to pay when you or a covered dependent have a stay in an inpatient facility.
This copayment is equal to a facility’s semi-private room rate for one day. For the stay of a well newborn baby,
starting at birth, this amount will not exceed the facility’s actual room and board charge on the first day of the
stay.
Coinsurance
This is the percentage of covered services you pay after your deductible.
81
Maximum out-of-pocket l imit
The maximum out-of-pocket limit is the most you will pay per year in copayments, coinsurance and deductible,
if any, for covered services. Covered services that are subject to the maximum out-of-pocket limit include
those provided under the medical plan and the outpatient prescription drug plan.
In-network covered services will apply only to the in-network maximum out-of-pocket limit. Out-of-network
covered services will apply only to the out-of-network maximum out-of-pocket limit.
Individual maximum out-of-pocket limit
• This plan may have an individual and family maximum out-of-pocket limit. As to the individual
maximum out-of-pocket limit, each of you must meet your maximum out-of-pocket limit separately.
• After you or your covered dependents meet the individual maximum out-of-pocket limit, this plan will
pay 100% of the eligible charge for covered services that would apply toward the limit for the rest of the
year for that person.
Family maximum ou t-of-pocket limit
After you or your covered dependents meet the family maximum out-of-pocket limit, this plan will pay 100% of
the eligible charge for covered services that would apply toward the limit for the remainder of the year for all
covered family members. The family maximum out-of-pocket limit is a cumulative maximum out-of-pocket
limit for all family members.
To satisfy this maximum out-of-pocket limit for the rest of the year, the following must happen:
• The family maximum out-of-pocket limit is met by a combination of family members
• No one person within a family will contribute more than the individual maximum out-of-pocket limit
amount in a year
If the maximum out-of-pocket limit does not apply to a covered service, your cost share for that service will not
count toward satisfying the maximum out-of-pocket limit amount.
Certain costs that you have do not apply toward the maximum out-of-pocket limit. These include:
• All costs for non-covered services which are identified in the certificate and the schedule
• Charges, expenses or costs in excess of the allowable amount
• Costs for non-urgent use of an urgent care provider
Limit provisions
Covered services will apply to the in-network and out-of-network limits.
Your financial responsibility and decisions regarding benefits
We base your financial responsibility for the cost of covered services on when the service or supply is provided,
not when payment is made. Benefits will be pro-rated to account for treatment or portions of stays that occur in
more than one year. Decisions regarding when benefits are covered are subject to the terms and conditions of
the group policy.
Outpatient pr escription drug deductible provisions
Covered services that are subject to the deductible include covered services provided under the medical plan
and the prescription drug plan.
The deductible may not apply to certain covered services. You still pay the copayment or coinsurance, if any,
for these covered services.
Outpatient pr escription drug maximum out-of-pocket limit provisions
Covered services that are subject to the maximum out-of-pocket limit include covered services provided under
the medical plan and the prescription drug plan.
The maximum out-of-pocket limit is the most you will pay per year in copayments, coinsurance and deductible,
if any, for covered services. This plan may have an individual and family maximum out-of-pocket limit.
82
Covered services
Acupuncture
Description
In-network
Out-of-network
Other health care
Acupuncture
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Visit limit per year
XX
XX
XX
Ambulance services
Description
In-network
Out-of-network
Other health care
Emergency services
XX% per trip after
deductible
Paid same as in-network
Paid same as in-network
Description
In-network
Out-of-network
Other health care
Non-emergency services
XX% per trip after
deductible
XX% per trip after
deductible
XX% per trip after
deductible
Applied behavior analysis
Description
In-network
Out-of-network
Other health care
Applied behavior analysis
Autism spectrum disorder
Description
In-network
Out-of-network
Other health care
Diagnosis and testing
Treatment
Occupational (OT),
physical (PT) and speech
(ST) therapy for autism
spectrum disorder
83
Behavioral health
Mental health treatment
Coverage provided is the same as for any other illness
Description
In-network
Out-of-network
Other health care
Inpatient services-room
and board
including residential
treatment facility
$XX then the plan pays
XX% per admission after
deductible
XX% per admission after
deductible
$XX then the plan pays
XX% per admission after
deductible
Description
In-network
Out-of-network
Other health care
Outpatient office visit to
a physician or
behavioral health
provider
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Physician or behavioral
health provider
telemedicine
consultation
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Outpatient mental
health disorders
telemedicine cognitive
therapy consultations by
a physician or
behavioral health
provider
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Description
In-network
Out-of-network
Other health care
Other outpatient
services including:
• Behavioral health
services in the
home
• Partial
hospitalization
treatment
• Intensive
outpatient
program
The cost share doesn’t
apply to in-network peer
counseling support
services
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Description
In-network
Out-of-network
Other health care
Telemedicine provider
mental health disorders
consultation
Covered based on type of
service and provider from
which it is received
Not covered
Not covered
84
Substance related disorders treatment
Includes detoxification, rehabilitation and residential treatment facility
Coverage provided is the same as for any other illness
Description
In-network
Out-of-network
Other health care
Inpatient services-room
and board during a
hospital stay
$XX then the plan pays
XX% per admission after
deductible
XX% per admission after
deductible
$XX then the plan pays
XX% per admission after
deductible
Description
In-network
Out-of-network
Other health care
Outpatient office visit to
a physician or
behavioral health
provider
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Physician or behavioral
health provider
telemedicine
consultation
XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Outpatient telemedicine
cognitive therapy
consultations by a
physician or behavioral
health provider
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Description
In-network
Out-of-network
Other health care
Other outpatient
services including:
• Behavioral health
services in the
home
• Partial
hospitalization
treatment
• Intensive
outpatient
program
The cost share doesn’t
apply to in-network peer
counseling support
services
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Description
In-network
Out-of-network
Other health care
Telemedicine provider
substance related
disorders consultation
Covered based on type of
service and provider from
which it is received
Not covered
Not covered
85
Clinical trials
Description
In-network
Out-of- network
Other health care
Experimental or
investigational
therapies
Routine patient costs
Diabetic services, supplies, equipment, and self-care programs
Description
In-network
Out-of-network
Other health care
Diabetic services
Diabetic supplies
Diabetic equipment
Diabetic self-care
programs
Durable medical equipment (DME)
Description
In-network
Out-of-network
Other health care
DME
XX% per item after
deductible
XX% per item after
deductible
XX% per item after
deductible
Emergency services
Description
In-network
Out-of-network
Other health care
Emergency room
$XX then the plan pays
XX% per visit after
deductible
Paid same as in-network
Paid same as in-network
Non-emergency care in
a hospital emergency
room
Not covered
Not covered
Not covered
86
Emergency services important note:
Out-of-network providers do not have a contract with us. The provider may not accept payment of your cost
share as payment in full. You may receive a bill for the difference between the amount billed by the provider
and the amount paid by the plan. If the provider bills you for an amount above your cost share, you are not
responsible for payment of that amount. You should send the bill to the address on your ID card and we will
resolve any payment issue with the provider. Make sure the member ID is on the bill. If you are admitted to
the hospital for an inpatient stay right after you visit the emergency room, you will not pay your emergency
room cost share if you have one. You will pay the inpatient hospital cost share, if any.
Habilitation therapy services
Physical (PT), occupational (OT) therapies
Description
In-network
Out-of-network
Other health care
PT, OT therapies
Speech therapy (ST)
Description
In-network
Out-of-network
Other health care
ST
Hearing aids
Description
In-network
Out-of-network
Other health care
Hearing aids
XX% per item after
deductible
XX% per item after
deductible
XX% per item after
deductible
Age limit
Covered persons through
age 18
Covered persons through
age 18
Covered persons through
age 18
Limit
One per ear every XX
months
One per ear every XX
One per ear every XX
months
Limit
$XX per ear
$XX per ear
$XX per ear
Hearing exams
Description
In-network
Out-of-network
Other health care
Hearing exams
Visit limit
1 visit every XX months
1 visit every XX months
1 visit every XX months
87
Home health care
A visit is a period of 4 hours or less
Description
In-network
Out-of-network
Other health care
Home health care
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Visit limit per year
XX
XX
XX
Home health care important note:
Intermittent visits are periodic and recurring visits that skilled nurses make to ensure your proper care. The
intermittent requirement may be waived to allow for coverage for up to 12 hours with a daily maximum of 3
visits.
Hospice care
Description
In-network
Out-of-network
Other health care
Inpatient services -
room and board
$XX then the plan pays
XX% per admission after
deductible
XX% after deductible
$XX then the plan pays
XX% per admission after
deductible
Description
In-network
Out-of-network
Other health care
Outpatient services
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Limit per lifetime
unlimited
unlimited
unlimited
Hospice important note:
This includes part-time or infrequent nursing care by an R.N. or L.P.N. to care for you up to 8 hours a day. It
also includes part-time or infrequent home health aide services to care for you up to 8 hours a day.
Hospital care
Description
In-network
Out-of-network
Other health care
Inpatient services –
room and board
$XX then the plan pays
XX% per admission, no
deductible applies
XX% after deductible
$XX then the plan pays
XX% per admission, no
deductible applies
Infertility services
Basic infertility
Description
In-network
Out-of-network
Other health care
Treatment of basic
infertility
88
Jaw joint disorder
Includes TMJ
Description
In-network
Out-of-network
Other health care
Jaw joint disorder
treatment
Maternity and related newborn care
Includes complications
Description
In-network
Out-of-network
Other health care
Inpatient services –
room and board
$XX then the plan pays
XX% per admission, no
deductible applies
XX% per admission after
deductible
$XX then the plan pays
XX% per admission, no
deductible applies
Services performed in
physician or specialist
office or a facility
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Other services and
supplies
XX%, no deductible
applies
XX% after deductible
XX%, no deductible
applies
Maternity and related newborn care important note:
Any cost share collected applies only to the delivery and postpartum care services provided by an OB, GYN or
OB/GYN. Review the Maternity section of the certificate. It will give you more information about coverage for
maternity care under this plan.
Oral and maxillofacial treatment (mouth, jaws and teeth)
Description
In-network
Out-of-network
Other health care
Treatment of mouth,
jaws and teeth
Outpatient pr escription drugs
Preferred generic prescription drugs
Description
In-network
Out-of-network
30 day supply at a retail
pharmacy
$XX, no deductible applies
$XX, no deductible applies
90 day supply at a retail
or mail order pharmacy
$XX, no deductible applies
$XX, no deductible applies
Preferred brand-name prescription drugs
Description
In-network
Out-of-network
30 day supply at a retail
pharmacy
$XX after deductible
$XX after deductible
90 day supply at a retail
or mail order pharmacy
$XX after deductible
$XX after deductible
89
Non-preferred generic prescription drugs
Description
In-network
Out-of-network
30 day supply at a retail
pharmacy
$XX, no deductible applies
$XX, no deductible applies
90 day supply at a retail
or mail order pharmacy
$XX, no deductible applies
$XX, no deductible applies
Non-preferred brand-name prescription drugs
Description
In-network
Out-of-network
30 day supply at a retail
pharmacy
$XX after deductible
$XX after deductible
90 day supply at a retail
or mail order pharmacy
$XX after deductible
$XX after deductible
Preferred specialty prescription drugs
Description
In-network
Out-of-network
30 day supply at a
specialty pharmacy
$XX after deductible
$XX then the plan pays XX% after
deductible
Non-preferred specialty prescription drugs
Description
In-network
Out-of-network
30 day supply at a
specialty pharmacy
$XX after deductible
$XX then the plan pays XX% after
deductible
Anti-cancer drugs taken by mouth
Description
In-network
Out-of-network
30 day supply at a
specialty pharmacy
$XX after deductible
$XX then the plan pays XX% after
deductible
Contraceptives (birth control)
Brand-name prescription drugs and devices are covered at 100% when a generic is not available
Description
In-network
Out-of-network
30 day supply of generic
and OTC drugs and
devices
$XX after deductible
Paid based on the tier of drug in the
schedule
30 day supply of brand-
name prescription drugs
and devices
Paid based on the tier of drug in the
schedule
Paid based on the tier of drug in the
schedule
90
Preventive care drugs and supplements
Description
In-network
Out-of-network
Preventive care drugs
and supplements
$XX, no deductible applies
Paid based on the tier of drug in the
schedule
Limits
Subject to any sex, age, medical
condition, family history and frequency
guidelines as recommended by the U.S.
Preventive Services Task Force (USPSTF)
For a current list of covered preventive
care drugs and supplements or more
information, see the Contact us section
Subject to any sex, age, medical
condition, family history and frequency
guidelines as recommended by the U.S.
Preventive Services Task Force (USPSTF)
For a current list of covered preventive
care drugs and supplements or more
information, see the Contact us section
Risk reducing breast cancer drugs
Description
In-network
Out-of-network
Risk reducing breast
cancer prescription
drugs
$XX, no deductible applies
Paid based on the tier of drug in the
schedule
Limits
Subject to any sex, age, medical
condition, family history and frequency
guidelines as recommended by the U.S.
Preventive Services Task Force (USPSTF)
For a current list of risk reducing breast
cancer drugs or more information, see
the Contact us section
Subject to any sex, age, medical
condition, family history and frequency
guidelines as recommended by the U.S.
Preventive Services Task Force (USPSTF)
For a current list of risk reducing breast
cancer drugs or more information, see
the Contact us section
Tobacco cessation drugs
Description
In-network
Out-of-network
Tobacco cessation
prescription and OTC
drugs
$XX, no deductible applies
Paid based on the tier of drug in the
schedule
Limits
Subject to any sex, age, medical
condition, family history and frequency
guidelines in the recommendations of
the USPSTF.
For a current list of covered tobacco
cessation drugs or more information,
see the Contact us section. See the
Other services section of this schedule
for more information.
Subject to any sex, age, medical
condition, family history and frequency
guidelines in the recommendations of
the USPSTF.
For a current list of covered tobacco
cessation drugs or more information,
see the Contact us section. See the
Other services section of this schedule
for more information.
Outpatient prescription drug important note:
If a provider prescribes a covered brand-name prescription drug when a generic prescription drug equivalent
is available and specifies “Dispense As Written” (DAW), you will pay the cost share for the brand-name drug. If
a provider does not specify DAW and you request a covered brand-name prescription drug, you will be
responsible for the cost difference between the brand-name drug and the generic drug, plus the cost share
that applies to the brand-name drug.
91
Outpatient surgery
Description
In-network
Out-of-network
Other health care
At hospital outpatient
department
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
At facility that is not a
hospital
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
At the physician office
Physician and specialist services
Physician services-general or family practitioner
Description
In-network
Out-of-network
Other health care
Physician office hours
(not-surgical, not
preventive)
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Physician surgical
services
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Description
In-network
Out-of-network
Other health care
Physician telemedicine
consultation
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Description
In-network
Out-of-network
Other health care
Telemedicine provider
consultation
Basic medical services
Covered based on type of
service and provider from
which it is received
Not covered
Not covered
Description
In-network
Out-of-network
Other health care
Physician visit during
inpatient stay
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Specialist
Description
In-network
Out-of-network
Other health care
Specialist office hours
(not-surgical, not
preventive)
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Specialist surgical
services
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Description
In-network
Out-of-network
Other health care
Specialist telemedicine
consultation
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
92
Description
In-network
Out-of-network
Other health care
Telemedicine provider
consultation
Specialist services
Covered based on type of
service and provider from
which it is received
Not covered
Not covered
All other services not shown above
Description
In-network
Out-of-network
Other health care
All other services
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
93
94
Preventive care
Description
In-network
Out-of-network
Other health care
Preventive care services
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies.
Breast feeding
counseling and support
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Breast feeding
counseling and support
limit
6 visits in a group or
individual setting
Visits that exceed the
limit are covered under
the physician services
office visit
6 visits in a group or
individual setting
Visits that exceed the
limit are covered under
the physician services
office visit
6 visits in a group or
individual setting
Visits that exceed the
limit are covered under
the physician services
office visit
Breast pump,
accessories and supplies
limit
Electric pump: 1 every 1
year
Manual pump: 1 per
pregnancy
Pump supplies and
accessories: 1 purchase
per pregnancy if not
eligible to purchase a new
pump
Electric pump: 1 every 1
year
Manual pump: 1 per
pregnancy
Pump supplies and
accessories: 1 purchase
per pregnancy if not
eligible to purchase a new
pump
Electric pump: 1 every 1
year
Manual pump: 1 per
pregnancy
Pump supplies and
accessories: 1 purchase
per pregnancy if not
eligible to purchase a new
pump
Breast pump waiting
period
Electric pump: 1 year to
replace an existing
electric pump
Electric pump: 1 year to
replace an existing
electric pump
Electric pump: 1 year to
replace an existing
electric pump
Counseling for alcohol or
drug misuse
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Counseling for alcohol or
drug misuse visit limit
5 visits/12 months
5 visits/12 months
5 visits/12 months
Counseling for obesity,
healthy diet
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Counseling for obesity,
healthy diet visit limit
Age 0-22: unlimited visits
Age 22 and older: 26
visits per 12 months, of
which up to 10 visits may
be used for healthy diet
counseling.
Age 0-22: unlimited visits
Age 22 and older: 26
visits per 12 months, of
which up to 10 visits may
be used for healthy diet
counseling.
Age 0-22: unlimited visits
Age 22 and older: 26
visits per 12 months, of
which up to 10 visits may
be used for healthy diet
counseling.
Counseling for sexually
transmitted infection
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Counseling for sexually
transmitted infection
visit limit
2 visits/12 months
2 visits/12 months
2 visits/12 months
Counseling for tobacco
cessation
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Counseling for tobacco
cessation visit limit
8 visits/12 months
8 visits/12 months
8 visits/12 months
Family planning services
XX% per visit, no
XX% per visit after
XX% per visit, no
95
(female contraception
counseling)
deductible applies
deductible
deductible applies
Family planning services
(female contraception
counseling) limit
Contraceptive counseling
limited to 2 visits/12
months in a group or
individual setting
Contraceptive counseling
limited to 2 visits/12
months in a group or
individual setting
Contraceptive counseling
limited to 2 visits/12
months in a group or
individual setting
Immunizations
XX%, no deductible
applies
XX% after deductible
XX%, no deductible
applies
Immunizations limit
Subject to any age limits
provided for in the
comprehensive guidelines
supported by the
Advisory Committee on
Immunization Practices of
the Centers for Disease
Control and Prevention
For details, contact your
physician
Subject to any age limits
provided for in the
comprehensive guidelines
supported by the
Advisory Committee on
Immunization Practices of
the Centers for Disease
Control and Prevention
For details, contact your
physician
Subject to any age limits
provided for in the
comprehensive guidelines
supported by the
Advisory Committee on
Immunization Practices of
the Centers for Disease
Control and Prevention
For details, contact your
physician
Routine cancer
screenings
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Routine cancer
screening limits
Subject to any age, family
history and frequency
guidelines as set forth in
the most current:
Evidence-based items
that have
a rating of A or
B in the current
recommendations of the
USPSTF
The comprehensive
guidelines supported by
the Health Resources and
Services Administration
For more information
contact your physician or
see the Contact us
section
Subject to any age, family
history and frequency
guidelines as set forth in
the most current:
Evid
ence-based items
that have a ratin
g of A or
B in the current
recommendations of the
USPSTF
The comprehensive
guidelines supported by
the Health Resources and
Services Administration
For more information
contact your physician or
see the Contact us
section
Subject to any age, family
history and frequency
guidelines as set forth in
the most current:
Evid
ence-based items
that have a ratin
g of A or
B in the current
recommendations of the
USPSTF
The comprehensive
guidelines supported by
the Health Resources and
Services Administration
For mo
re information
contact your physician or
see the Contact us
section
Routine lung cancer
screening
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Routine lung cancer
screening limit
1 screenings every 12
months
Screenings that exceed
this limit covered as
outpatient diagnostic
testing
1 screenings every 12
months
Screenings that exceed
this limit covered as
outpatient diagnostic
testing
1 screenings every 12
months
Screenings that exceed
this limit covered as
outpatient diagnostic
testing
96
Routine physical exam
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Routine physical exam
limits
Subject to any age and
visit limits provided for in
the comprehensive
guidelines supported by
the American Academy of
Pediatrics/Bright
Futures/Health Resources
and Services
Administration for
children and adolescents
Limited to 7 exams from
age 0-1 year; 3 exams
every 12 months age 1-2;
3 exams every 12 months
age 2-3; and 1 exam
every 12 months after
that age, up to age 22; 1
exam every 12 months
after age 22
High risk Human
Papillomavirus (HPV) DNA
testing for woman age 30
and older limited to 1
every 36 months
Subject to any age and
visit limits provided for in
the comprehensive
guidelines supported by
the American Academy of
Pediatrics/Bright
Futures/Health Resources
and Services
Administration for
children and adolescents
Limited to 7 exams from
age 0-1 year; 3 exams
every 12 months age 1-2;
3 exams every 12 months
age 2-3; and 1 exam
every 12 months after
that age, up to age 22; 1
exam every 12 months
after age 22
High risk Human
Papillomavirus (HPV) DNA
testing for woman age 30
and older limited to 1
every 36 months
Subject to any age and
visit limits provided for in
the comprehensive
guidelines supported by
the American Academy of
Pediatrics/Bright
Futures/Health Resources
and Services
Administration for
children and adolescents
Limited to 7 exams from
age 0-1 year; 3 exams
every 12 months age 1-2;
3 exams every 12 months
age 2-3; and 1 exam
every 12 months after
that age, up to age 22; 1
exam every 12 months
after age 22
High risk Human
Papillomavirus (HPV) DNA
testing for woman age 30
and older limited to 1
every 36 months
Well woman GYN exam
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Well woman GYN exam
limit
Subject to any age and
visit limits provided for in
the comprehensive
guidelines supported by
the Health Resources and
Services Administration
Subject to any age and
visit limits provided for in
the comprehensive
guidelines supported by
the Health Resources and
Services Administration
Subject to any age and
visit limits provided for in
the comprehensive
guidelines supported by
the Health Resources and
Services Administration
Limit
1 visit
1 visit
1 visit
Prosthetic devices
Description
In-network
Out-of-network
Other health care
Prosthetic devices
97
Reconstructive sur gery and supplies
Including breast surgery
Description
In-network
Out-of-network
Other health care
Surgery and supplies
Short-term rehabilitation services
Cardiac rehabilitation
Description
In-network
Out-of-network
Other health care
Cardiac rehabilitation
Pulmonary rehabilitation
Description
In-network
Out-of-network
Other health care
Pulmonary
Cognitive rehabilitation
Description
In-network
Out-of-network
Other health care
Cognitive rehabilitation
Physical, occupational and speech therapies
Description
In-network
Out-of-network
Other health care
$XX then the plan pays
XX% per visit no
deductible applies
XX% per visit after
deductible
XX% per visit no
deductible applies
Physical, occupational and speech therapies
Description
In-network
Out-of-network
Other health care
Visit limit per year
All therapies combined
In-network and out-of-
network combined
XX
XX
XX
Spinal manipulation
Description
In-network
Out-of-network
Other health care
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Visit limit per year
In-network and out-of-
network combined
XX
XX
XX
98
Skilled nursing facility
Description
In-network
Out-of-network
Other health care
Inpatient services -
room and board
$XX then the plan pays
XX% per admission
after deductible
XX% per admission
after deductible
$XX then the plan pays
XX% per admission
after deductible
Other inpatient
services and supplies
XX% per admission
after deductible
XX% per admission
after deductible
XX% per admission
after deductible
Day limit per year XX XX XX
Tests, images and labs – outpatient
Diagnostic complex imaging services
Description
In-network
Out-of-network
Other health care
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Diagnostic lab work
Description
In-network
Out-of-network
Other health care
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Diagnostic x-ray and other radiological services
Description
In-network
Out-of-network
Other health care
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Therapies
Chemotherapy
Description
In-network
Out-of-network
Other health care
Chemotherapy services
Gene-based, cellular and other innovative therapies (GCIT)
Description
In-network (GCIT-designated
facility/provider)
Out-of-network
(Including providers who are otherwise
part of Aetna’s network but are not
GCIT-designated facilities/providers)
Services and supplies
Covered based on type of service and
where it is received
Covered based on type of service and
where it is received
99
Infusion therapy
Outpatient services
Description
In-network
Out-of-network
Other health care
In physician office
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
At an infusion location
In the home
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
At hospital outpatient
department
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
At facility that is not a
hospital
XX% per visit, no
deductible applies
XX% per visit after
deductible
XX% per visit, no
deductible applies
Radiation therapy
Description
In-network
Out-of-network
Other health care
Radiation therapy
Respiratory therapy
Description
In-network
Out-of-network
Other health care
Respiratory therapy
Transplant services
Description
In-network (IOE facility)
Out-of-network
(Includes providers who are otherwise
part of Aetna’s network but are non-IOE
providers)
Inpatient services and
supplies
$XX then the plan pays XX% per
transplant after deductible
XX% per transplant after deductible
Physician services
Covered based on type of service and
where it is received
Covered based on type of service and
where it is received
100
Urgent ca re services
At a freestanding facility or provider that is not a hospital
A separate urgent care cost share will apply for each visit to an urgent care facility or provider
Description
In-network
Out-of- network
Other health care
Urgent care facility
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
$XX then the plan pays
XX% per visit, no
deductible applies
Non-urgent use of an
urgent care facility or
provider
Not covered
Not covered
Not covered
Vision care
Performed by an ophthalmologist or optometrist and includes refraction
Description
In-network
Out-of-network
Other health care
$XX then the plan pays
XX% per visit after
deductible
XX% per visit after
deductible
XX% per visit after
deductible
Visit limit
1 visit every 24 months
1 visit every 24 months
1 visit every 24 months
Walk-in clinic
Not all preventive care services are available at a walk-in clinic. All services are available from a
network physician.
Description
Designated network
Non-designated
network
Out-of-network
Non-emergency services
XX% per visit, no
deductible applies
$XX then the plan pays
XX% per visit, no
deductible applies
XX% per visit after
deductible
Preventive care
immunizations
XX% per visit, no
deductible applies
XX% per visit, no
deductible applies
XX% per visit after
deductible
Immunization limits
Subject to any age and
frequency limits provided
for in the comprehensive
guidelines supported by
the Advisory Committee
on Immunization
Practices of the Centers
for Disease Control and
Prevention
For details, contact your
physician
Subject to any age and
frequency limits provided
for in the comprehensive
guidelines supported by
the Advisory Committee
on Immunization Practices
of the Centers for Disease
Control and Prevention
For details, contact your
physician
Subject to any age and
frequency limits provided
for in the comprehensive
guidelines supported by
the Advisory Committee
on Immunization
Practices of the Centers
for Disease Control and
Prevention
For details, contact your
physician
Preventive screening
and counseling services
XX% per visit, no
deductible applies
XX% per visit, no
deductible applies
XX% per visit after
deductible
Preventive screening
and counseling limits
See the Preventive care
services section of the
schedule
See the Preventive care
services section of the
schedule
See the Preventive care
services section of the
schedule
101
Telemedicine
consultation for non-
emergency services
through a walk-in clinic
XX% per visit, no
deductible applies
Not covered
Telemedicine
consultation for
preventive screening
and counseling services
through a walk-in clinic
XX% per visit, no
deductible applies
Not covered
Important Note:
Key terms
Designated network provider
A network provider listed in the directory under Best Results for your plan as a provider for your plan.
Non-designated network provider
A provider listed in the directory under the All other results tab as a provider for your plan.
See the Contact us section if you have questions.
You will pay less cost share when you use a designated network walk-in clinic provider. Non-designated
network walk-in clinic providers are available to you, but the cost share will be at a higher level when these
providers are used.
