Consumer Disclosure Information Texas by MikeJenny


									Consumer Disclosure Information
Quality Point-of-Service® (HMO portion only)
USAccess® (HMO portion only)

Type of Coverage                                                 The Office of the Ombudsman can give members helpful
Aetna Health Inc. is licensed by the Texas Department of         information about our processes (such as understanding
Insurance to operate as a Health Maintenance                     the complaint or appeal process or how out-of-network
Organization (HMO) within an approved service area.              referral requests work, or if you believe you have been
                                                                 discriminated against based on your health status). If you
                                                                 need help understanding how your HMO-based plan
Additional Information                                           works, the Office of the Ombudsman is here to assist you.
You may call 1-888-982-3862 or write to Aetna, P.O. Box          Call (toll-free) 877-368-8299 whenever you feel you need
569441, Dallas, TX 75356-9441 if you wish to obtain              additional information or expertise.
additional information, including provider information.
                                                                 Dependent Eligibility (if your employer
Office of the Ombudsman                                          provides coverage for dependent
The Office of the Ombudsman will assist members in               children)
understanding Aetna’s HMO-based plans, the coverage
                                                                 Your unmarried children are eligible for coverage if they
offered and the network providers participating in these
                                                                 are less than 25 years old. Student status is not required
plans. The Office of the Ombudsman will also assist
                                                                 for initial enrollment or to continue coverage.
members in obtaining medically necessary covered
benefits. If requested, the Office of the Ombudsman can          Your unmarried grandchildren are eligible for coverage if
assist during internal appeals and independent review            they are (i) less than 25 years old and (ii) your dependents
proceedings.                                                     for federal income tax purposes at the time of application
                                                                 for coverage. Student status is not required for initial
The Office of the Ombudsman is not intended to replace
                                                                 enrollment or to continue coverage.
Aetna’s Member Services department. The Office of the
Ombudsman cannot help expedite a claim or make                   For further information concerning dependent eligibility,
medical necessity or coverage decisions. If you have basic       please contact your employer’s benefits manager or call us
questions (such as information about your benefits,              toll-free at 1-888-982-3862.
whether a provider is still part of our network, whether a
drug is on our formulary, how to obtain a formulary              Medically Necessary Covered Benefits
exception for medical reasons, how to obtain a new ID            A member shall be entitled to the medically necessary
card, etc.), you should always begin by calling the Member       covered benefits as specified in accordance with the terms
Services number on your ID card. You also should call            and conditions of the Certificate of Coverage which you
Member Services to file a complaint, appeal a denial of          will receive after enrollment in the HMO plan. This plan
care or request an out-of-network referral.                      does not provide coverage for all health care expenses and
                                                                 includes exclusions and limitations. These exclusions and
                                                                 limitations will be clearly and unambiguously disclosed in
                                                                 your Certificate of Coverage. Read your Certificate of
                                                                 Coverage carefully to determine which health care services
                                                                 are covered benefits and to what extent. Services and
                                                                 supplies that are generally not covered benefits are
                                                                 itemized in the “Exclusions and Limitations” section of this
                                                                 document (depending on the specific benefits offered by
                                                                 your employer).
01.28.302.1-TX (7/05)                                        1
You will receive your Certificate of Coverage after                    Aetna will not use any decision-making process that
enrollment, and you should consult that document to                    operates to deny medically necessary care that is a covered
determine the terms and conditions of your plan. To find               benefit under your Certificate. Since Aetna has authority
out before you enroll whether your Certificate of Coverage             to determine medical necessity for purposes of the
contains exclusions and limitations different from those               Certificate, a determination under the Certificate that a
listed in this document, contact your employer’s benefits              proposed course of treatment, health care service or supply
manager. You may also request a sample copy of the                     is not medically necessary may be made by Texas-licensed
Aetna Certificate of Coverage by calling us toll-free at               physicians other than the member’s provider. This means
1-888-982-3862.                                                        that, even if the member’s provider determines in his or
In order for benefits to be covered, they must be medically            her clinical judgment that a treatment, service or supply is
necessary and, in many cases, must also be pre-authorized              medically necessary for the Member, HMO’s Texas-licensed
by Aetna.                                                              physician may determine that it is not medically necessary
                                                                       under this Certificate. If Aetna determines that a service or
      “Medically necessary” services are those hospital or
                                                                       supply is not medically necessary for the member, the
      medical services and supplies that, under the
                                                                       member (or their authorized representative) may appeal to
      applicable standard of care, are appropriate: (a) to
                                                                       the Texas independent review organization, as described
      improve or preserve health, life, or function; or (b) to
                                                                       below in the section entitled “Complaints, Appeals and
      slow the deterioration of health, life, or function; or
                                                                       Independent Review.”
      (c) for the early screening, prevention, evaluation,
      diagnosis or treatment of a disease, condition, illness,         For the purpose of coverage, except for certain
      or injury.                                                       specialist benefits (referred to as “direct access”
                                                                       benefits) or in a medical emergency or an urgent
Determinations by the HMO of whether care is medically
                                                                       care situation outside the service area, the following
necessary under this definition shall also include
                                                                       benefits must be accessed through the primary care
determinations of whether the services and supplies are
                                                                       physician (PCP) or elsewhere upon prior referral
cost-effective, timely, and sufficient in quality, quantity, and
                                                                       issued by the member’s PCP. Although listed as covered
frequency, consistent with the applicable standard of care.
                                                                       below, benefits are subject to the exclusions and
For purposes of this definition, “cost-effective” means the
                                                                       limitations following this section and set out in further
least expensive medically necessary treatment selected
                                                                       detail in the Certificate of Coverage. Please review the
from two or more treatments that are equally effective,
                                                                       exclusions and limitations section in this document. To find
meaning the care can reasonably be expected to produce
                                                                       out before you enroll whether your Certificate of Coverage
the intended results and to have expected benefits that
                                                                       contains exclusions and limitations different from those
outweigh potential harmful effects, in achieving a desired
                                                                       listed in this document, contact your employer’s benefits
health outcome for that particular member. Medical
                                                                       manager, or call us toll-free at 1-888-982-3862.
necessity, when used in relation to services, shall have the
                                                                       Members are responsible for copayments in the
same meaning as medically necessary services. This
                                                                       amount specified in their benefit plan for each
definition applies only to the determination by the HMO of
                                                                       service or visit.
whether health care services are medically necessary
covered benefits under your Certificate of Coverage.                   I   Primary care physician and specialist physician (upon
                                                                           referral) outpatient and inpatient visits.
The determination of medically necessary care is an
analytical process applied on a case-by-case basis by                  I   Routine physical examinations; routine gynecological
qualified professionals who have the appropriate training,                 examinations for women, including pap smear; and
education, and experience and who possess the clinical                     well-child care from birth including immunizations and
judgment and case-specific information necessary to make                   booster doses according to the standards of the
these decisions. The determination of whether proposed                     Advisory Committee on Immunization Practices of the
care is a covered benefit is independent of, and should not                Centers for Disease Control, U.S. or as required by law.
be confused with, the determination of whether proposed                I   Colorectal cancer screening for members age 50 and
care is medically necessary.                                               older. This includes (i) a fecal occult blood test every
                                                                           year; and (ii) a flexible sigmoidoscopy every 5 years or a
                                                                           colonoscopy every 10 years.
                                                                       I   Prostate cancer screening for men (i) age 50 and older
                                                                           and (ii) ages 40-49 who have an increased risk of
                                                                           developing prostate cancer.

I   Routine vision, speech and hearing screenings (including                  I   Inpatient rehabilitation benefits are covered for
    newborns).                                                                    medical, nursing, counseling or therapeutic
I   Injections, including allergy desensitization injections.                     rehabilitation services in an appropriately licensed
                                                                                  participating facility upon referral by the member’s
I   Diagnostic, laboratory, x-ray services; mammograms;
                                                                                  participating behavioral health provider for chemical
    prostate cancer screening; and osteoporosis screening.
I   Cancer chemotherapy and cancer hormone treatments
                                                                          I   Mental Health Benefits. A member is covered for
    and services which have been approved by the United
                                                                              services for the treatment of mental or behavioral
    States Food and Drug Administration for general use in
                                                                              conditions provided through participating behavioral
    treatment of cancer.
                                                                              health providers.
I   Diagnosis and treatment of gynecological or infertility
                                                                          I   Up to 20 outpatient visits are covered for short-term,
    problems by participating gynecologists or participating
                                                                              outpatient evaluative and crisis intervention or home
    infertility specialists. Benefits for infertility treatment are
                                                                              health mental health services.
    limited and you should call 1-800-575-5999 for more
    information regarding coverage under your specific                    I   Serious mental illness: diagnosis and medical treatment
    health plan.                                                              of a serious mental illness. Serious mental illness means
                                                                              the following psychiatric illnesses (as defined by the
I   Outpatient and inpatient pre-natal and postpartum care
                                                                              American Psychiatric Association in the Diagnostic and
    and obstetrical services.
                                                                              Statistical Manual (DSM)III-R): schizophrenia; paranoid
I   Inpatient hospital & skilled nursing facility benefits.                   and other psychotic disorders; bipolar disorders
    Except in an emergency, all services are subject to                       (hypomanic; mixed, manic and depressive); major
    preauthorization by HMO. Coverage for skilled nursing                     depressive disorders (single episode or recurrent); schizo-
    facility benefits is subject to the maximum number of                     affective disorders (bipolar or depressive); pervasive
    days, if any, listed in your specific health plan.                        developmental disorders; obsessive-compulsive disorders
I   Transplants which are non-experimental or non-                            and depression in childhood and adolescence.
    investigational. Covered transplants must be approved                     I   Inpatient benefits are provided for a maximum of 45
    by HMO’s medical director in advance of the surgery.                          days per calendar year.
    The transplant must be performed at a hospital
                                                                              I   Outpatient benefits are provided for a maximum of
    specifically approved and designated by HMO to
                                                                                  60 visits per calendar year.
    perform these procedures. If HMO denies coverage of
    a transplant based on lack of medical necessity, the                  I   Emergency medical services, including
    member may request a review by an independent                             screening/evaluation to determine whether an
    review organization (IRO). More information can be                        emergency medical condition exists, and emergency
    found below in the “Complaints, Appeals and                               medical transportation. See the “Emergency Care”
    Independent Review” section.                                              section, below. As a reminder, a referral from your PCP
                                                                              is not required for this service.
I   Outpatient surgical services and supplies in connection
    with a covered surgical procedure. Non-emergency                      I   Urgent, non-emergent care services obtained from a
    services and supplies are subject to preauthorization by                  licensed physician or facility outside of the service area if
    HMO.                                                                      (i) the service is a covered benefit; (ii) the service is
                                                                              medically necessary and immediately required because
I   Chemical Dependency/Substance Abuse Benefits. There
                                                                              of unforeseen illness, injury, or condition; and (iii) it was
    is a lifetime maximum of 3 treatment episodes for
                                                                              not reasonable, given the circumstances, for the
    inpatient hospital, inpatient treatment facility, partial
                                                                              member to return to the HMO service area for
    hospitalization and outpatient treatment combined.
                                                                              treatment. As a reminder, a referral from your PCP is
    I   Outpatient and inpatient care benefits are covered                    not required for this service.
        for detoxification.
                                                                          I   Inpatient and outpatient physical, occupational and
    I   Outpatient rehabilitation visits are covered to a                     speech rehabilitation services when they are medically
        participating behavioral health provider upon referral                necessary and meet or exceed the treatment goals
        by the PCP for diagnostic, medical or therapeutic                     established for the patient.
        rehabilitation services for chemical dependency.
    Aetna will not exclude coverage for cognitive                     I   Certain infertility services. Refer to the “Covered
    rehabilitation therapy, cognitive communication therapy,              Benefits” section of the Certificate of Coverage for
    neurocognitive therapy and rehabilitation,                            detailed information. Benefits for infertility treatment
    neurobehavioral, neurophysiological,                                  are limited and you should call 1-800-575-5999 for
    neuropsychological, and psychophysiological testing or                more information regarding coverage under your
    treatment, neurofeedback therapy, remediation, post-                  specific health plan.
    acute transition services, or community reintegration             I   Coverage is provided for formulas necessary for the
    services necessary as a result of and related to an                   treatment of phenylketonuria or other heritable diseases
    acquired brain injury.                                                to the same extent as for drugs available only on the
I   Cardiac rehabilitation benefits following an inpatient                orders of a physician.
    hospital stay. A limited course of outpatient cardiac
    rehabilitation is covered following angioplasty,                  Prescription Drugs
    cardiovascular surgery, congestive heart failure or               Generally, except for insulin, outpatient prescription drugs
    myocardial infarction.                                            are covered only if your health plan includes a rider for
I   Home health benefits rendered by a participating home             such coverage. If your plan covers outpatient prescription
    health care agency. Preauthorization must be obtained             drugs, your plan may include a preferred drug list (also
    from the member’s attending participating physician.              known as a “drug formulary”). The preferred drug list
    Home health benefits are not covered if HMO                       includes a list of prescription drugs that, depending on
    determines the treatment setting is not appropriate, or           your prescription drug benefits plan, are covered on a
    if there is a more cost effective setting in which to             preferred basis. Many drugs, including many of those listed
    provide appropriate care.                                         on the preferred drug list, are subject to rebate
I   Hospice care medical benefits when preauthorized by               arrangements between Aetna and the manufacturer of the
    HMO.                                                              drugs. Such rebates are not reflected in and do not reduce
                                                                      the amount a member pays for a prescription drug. In
I   Initial provision of prosthetic appliances. Covered               addition, in circumstances where your prescription plan
    prosthetic appliances generally include those items               utilizes copayments or coinsurance calculated on a
    covered by Medicare unless otherwise excluded under               percentage basis or a deductible, your costs may be higher
    your specific health plan.                                        for a preferred drug than they would be for a
I   Certain injectable medications when an oral alternative           nonpreferred drug. For information regarding how
    drug is not available and when preauthorized by HMO,              medications are reviewed and selected for the preferred
    unless excluded under your specific health plan.                  drug list, please refer to Aetna’s website at
I   Mastectomy-related services including reconstructive     or the Aetna Preferred Drug (Formulary)
    breast surgery, prostheses and lymphedema, as                     Guide. Printed Preferred Drug Guide information will be
    described in your specific health plan.                           provided, upon request or if applicable, annually for
                                                                      current members and upon enrollment for new members.
I   Voluntary sterilizations.                                         Additional information can be obtained by calling Member
I   Administration, processing of blood, processing fees,             Services at the toll-free number listed on your member ID
    and fees related to autologous blood donations only.              card. The medications listed on the preferred drug list are
I   Diagnostic and surgical treatment of the                          subject to change in accordance with applicable state law.
    temporomandibular joint that is medically necessary as a          Your prescription drug benefit is generally not limited to
    result of an accident, a trauma, a congenital defect, a           drugs listed on the preferred drug list. Medications that are
    developmental defect or a pathology.                              not listed on the preferred drug list (nonpreferred or
I   Diabetic outpatient self-management training and                  nonformulary drugs) may be covered subject to the limits
    education (including medical nutrition therapy for the            and exclusions set forth in your plan documents.
    treatment of diabetes), equipment and supplies                    Covered nonformulary prescription drugs may be subject
    (including blood glucose monitors and monitor-related             to higher copayments or coinsurance under some benefit
    supplies including test strips and lancets; injection aids;       plans. Some prescription drug benefit plans may exclude
    syringes and needles; insulin infusion devices; and               from coverage certain nonformulary drugs that are not
    insulin and other pharmacological agents for controlling          listed on the preferred drug list. If it is medically necessary
    blood sugar).                                                     for members enrolled in these benefit plans to use such
                                                                      drugs, their physicians (or pharmacist in the case of
                                                                      antibiotics and analgesics) may contact Aetna to request
                                                                      coverage as a medical exception. Check your plan
                                                                      documents for details.

In addition, certain drugs may require precertification or         More information on these topics can be found below
step-therapy before they will be covered under some                under “Prescription Drugs” in the section entitled
prescription drug benefit plans. Step-therapy is a different       “Precertification and Other Review Processes.” The
form of precertification which requires a trial of one or          member (or their authorized representative) may appeal
more “prerequisite therapy” medications before a “step             denials of coverage for medications under their pharmacy
therapy” medication will be covered. If it is medically            benefit plan to the Texas independent review organization,
necessary for a member to use a medication subject to              as described below in the section entitled “Complaints,
these requirements, the member’s physician can request             Appeals and Independent Review.”
coverage of such drug as a medical exception. In addition,
some benefit plans include a mandatory generic drug cost-          Emergency Care
sharing requirement. In these plans, you may be required
                                                                   If you need emergency care, you are covered 24 hours a
to pay the difference in cost between a covered brand-
                                                                   day, 7 days a week, anywhere in the world. An
name drug and its generic equivalent in addition to your
                                                                   emergency medical condition means health care services
copayment if you obtain the brand-name drug.
                                                                   provided in a hospital emergency facility or comparable
Nonprescription drugs and drugs in the Limitations and
                                                                   facility to evaluate and stabilize medical conditions of a
Exclusions section of the plan documents (received and/or
                                                                   recent onset and severity, including but not limited to
available upon enrollment) are not covered, and medical
                                                                   severe pain, that would lead a prudent layperson,
exceptions are not available for them.
                                                                   possessing an average knowledge of medicine and health,
Depending on the plan selected, new prescription drugs             to believe that his or her condition, sickness, or injury is of
not yet reviewed for possible addition to the preferred            such a nature that failure to get immediate medical care
drug list are either available at the highest copay under          could result in: (1) placing the patient’s health in serious
plans with an “open” formulary, or excluded from                   jeopardy; (2) serious impairment to bodily functions; (3)
coverage unless a medical exception is obtained under              serious dysfunction of any bodily organ or part; (4) serious
plans that use a “closed” formulary. These new drugs may           disfigurement; or (5) in the case of a pregnant woman,
also be subject to precertification or step-therapy.               serious jeopardy to the health of the fetus.
Members should consult with their treating physicians              In determining whether services provided to you will be
regarding questions about specific medications. Refer to           covered as emergency services, we have the right to review
your plan documents or contact Member Services for                 the services and the circumstances in which you received
information regarding terms, conditions and limitations of         them.
coverage. If you use the mail order prescription program of
                                                                   I   If your condition is an emergency, we will cover the
Aetna Rx Home Delivery, LLC, you will be acquiring these
                                                                       medical screening examination, evaluation, stabilization
prescriptions through an affiliate of Aetna. Aetna’s
                                                                       and treatment.
negotiated charge with Aetna Rx Home Delivery® may be
higher than Aetna Rx Home Delivery’s cost of purchasing            I   If your condition is not an emergency, we will cover only
drugs and providing mail-order pharmacy services. For                  the medical screening examination and evaluation. You
these purposes, Aetna Rx Home Delivery’s cost of                       will be responsible for the other charges.
purchasing drugs takes into account discounts, credits and         Whether you are within or outside of your Aetna HMO
other amounts that it may receive from wholesalers,                service area, we simply ask that you follow the guidelines
manufacturers, suppliers and distributors.                         below when you believe you need emergency care.
If you use the Aetna Specialty PharmacySM specialty drug           1. Call the local emergency hotline (ex. 911) or go to the
program, you will be acquiring these prescriptions through            nearest emergency facility. If a delay would not be
Aetna Specialty Pharmacy, LLC, which is jointly owned by              detrimental to your health, call your primary care
Aetna and Priority Healthcare, Inc. Aetna’s negotiated                provider. Notify your primary care provider as soon as
charge with Aetna Specialty Pharmacy may be higher than               possible after receiving treatment.
Aetna Specialty Pharmacy’s cost of purchasing drugs and            2. After assessing and stabilizing your condition, the
providing specialty pharmacy services. For these purposes,            emergency facility should contact your primary care
Aetna Specialty Pharmacy’s cost of purchasing drugs takes             physician so they can assist the treating physician by
into account discounts, credits and other amounts that it             supplying information about your medical history.
may receive from wholesalers, manufacturers, suppliers
                                                                   3. If you are admitted to an inpatient facility, you or a
and distributors.
                                                                      family member or friend acting on your behalf should
                                                                      notify your primary care physician or Aetna as soon as
Follow-up Care after Emergencies                                     Your Financial Responsibility
All follow-up care should be coordinated by your PCP.                You are responsible for all applicable copayments and
Follow-up care with nonparticipating providers is only               premiums under your particular plan. Please refer to the
covered with a referral from your primary care physician             plan design overview contained in your pre-enrollment
and pre-approval from Aetna. Whether you were treated                packet for a brief description of these provisions. In
within or outside of your Aetna service area, you must               addition, you are also financially responsible for all non-
obtain a referral before any follow-up care can be covered.          covered services and, in some cases, out-of-area expenses.
Suture removal, cast removal, X-rays and clinic or                   (Out-of-area emergency and urgent care expenses are
emergency room revisits are examples of follow-up care.              reimbursed by the health plan.) Should you receive a bill
                                                                     for covered services from your participating physician or
Accessing Care After Hours                                           provider, please contact Member Services at the number
                                                                     on your ID card or at 1-888-982-3862. Participating
You can call your primary care physician’s (PCP’s) office 24
                                                                     physicians and providers have agreed to look exclusively to
hours a day, seven days a week if you have medical
                                                                     Aetna for payment of covered services.
questions or concerns. If you need after-hours treatment
for a problem such as fever, earache, sore throat, sprained
ankle, minor laceration, vomiting or diarrhea, you should            Exclusions and Limitations
consider an urgent care facility.                                    The following is a summary of services that are not
                                                                     covered unless your employer has included them in your
Urgent Care                                                          plan or purchased a separate, optional rider. Additional
                                                                     exclusions and limitations may apply for your specific plan,
When you need urgent care (not emergency care), your
                                                                     so your Certificate of Coverage should be consulted for
PCP may direct you to an urgent care facility, to provide
                                                                     more detail. To find out before you enroll whether your
you convenient and timely care. For up-to-date listings of
                                                                     Certificate of Coverage contains different exclusions and
participating urgent care centers, visit our DocFind® online
                                                                     limitations, contact your employer’s benefits manager or
provider directory at You do not need
                                                                     call us toll-free at 1-888-982-3862.
a referral from your PCP to visit a participating urgent care.
What To Do Outside Your Aetna HMO                                    I   Acupuncture and acupuncture therapy, except when
Service Area                                                             performed by a participating physician as a form of
                                                                         anesthesia in connection with covered surgery.
Members who are traveling outside their HMO service area
or students who are away at school are covered for                   I   Ambulance or medical transportation services for non-
emergency services and urgently needed care. Urgent care                 emergency transportation.
means covered benefits provided in a non-emergency                   I   Bereavement counseling, funeral arrangements, pastoral
situation as a result of an acute injury or illness that is              counseling, financial or legal counseling, homemaker or
severe or painful enough to lead a prudent layperson,                    caretaker services, respite care, and any service not
possessing an average knowledge of medicine and health,                  solely related to the care of the member, including but
to believe that his or her condition, illness or injury is of            not limited to, sitter or companion services for the
such a nature that failure to obtain treatment within a                  member or other members of the family, transportation,
reasonable period of time would result in serious                        house cleaning, and maintenance of the house.
deterioration of the condition or his or her health. Certain         I   Biofeedback.
conditions, such as severe vomiting, earaches, sore throats
                                                                     I   Blood and blood plasma, including provision of blood,
or fever, are considered “urgent care” when they occur
                                                                         blood plasma, blood derivatives, synthetic blood or
outside your Aetna HMO service area. Urgent care may be
                                                                         blood products other than blood-derived clotting
obtained from a private practice physician, a walk-in clinic,
                                                                         factors, the collection or storage of blood plasma, the
an urgent care center or an emergency facility.
                                                                         cost of receiving the services of professional blood
                                                                         donors, apheresis (removal of the plasma) or
                                                                         plasmapheresis (cleaning and filtering of the plasma).
                                                                         Only administration, processing of blood, processing
                                                                         fees, and fees related to autologous blood donations
                                                                         are covered.
                                                                     I   Care for conditions that state or local law require to be
                                                                         treated in a public facility, including but not limited to
                                                                         mental illness commitments.

I   Care furnished to provide a safe surrounding, including           I   Experimental or investigational procedures or ineffective
    the charges for providing a surrounding free from                     surgical, medical, psychiatric or dental treatments or
    exposure that can worsen the disease or injury.                       procedures, research studies, or other experimental or
    Examples include asbestos removal, air filtration, and                investigational health care procedures or
    special ramps or doorways.                                            pharmacological regimes as determined by HMO, unless
I   Cosmetic surgery, or treatment relating to the                        pre-authorized by HMO. This exclusion will not apply
    consequences of, or as a result of, Cosmetic Surgery,                 with respect to drugs: (i) that have been granted
    including but not limited to surgery to correct                       treatment investigational new drug (IND) or Group
    gynecomastia, breast augmentation, and otoplasties.                   c/treatment IND status; (ii) that are being studied at the
    This exclusion does not apply to (i) surgery to restore               Phase III level in a national clinical trial sponsored by the
    normal bodily functions, including but not limited to,                National Cancer Institute; or (iii) HMO has determined
    cleft lip and cleft palate or as a continuation of a staged           that available scientific evidence demonstrates that the
    reconstruction procedure, or congenital defects; (ii)                 drug is effective or the drug shows promise of being
    breast reconstruction following a mastectomy, including               effective for the disease.
    the breast on which mastectomy surgery has been                   I   Hair analysis.
    performed and the breast on which mastectomy surgery              I   Health services, including those related to pregnancy,
    has not been performed; and (iii) reconstructive surgery              rendered before the effective date or after the
    performed on a member who is less than 18 years of                    termination of the member’s coverage.
    age to improve the function of or to attempt to create a
                                                                      I   Hearing aids.
    normal appearance of a craniofacial abnormality.
                                                                      I   Home births.
I   Costs for court-ordered services, or those required by
    court order as a condition of parole or probation.                I   Home uterine activity monitor.
I   Custodial care.                                                   I   Hypnotherapy.
I   Dental services, including false teeth. This exclusion            I   Infertility services not otherwise covered, including
    does not apply to: the removal of bone fractures,                     injectable infertility drugs, charges for the freezing and
    tumors, and orthodontogenic cysts; diagnostic and                     storage of cryopreserved embryos, charges for storage
    medical/surgical treatment of the temporomandibular                   of sperm, and donor costs, including but not limited to,
    joint disorder; or medical services required when the                 the cost of donor eggs and donor sperm, ovulation
    dental services cannot be safely provided in a dentist’s              predictor kits, and donor egg program or gestational
    office due to the member’s physical, mental or medical                carriers, ZIFT, GIFT or in-vitro fertilization. Call 1-800-
    condition.                                                            575-5999 for more information regarding exclusions.
I   Durable medical equipment and household equipment,                I   Injectable drugs, as follows: experimental drugs or
    including but not limited to crutches, braces, the                    medications, or drugs or medications that have not
    purchase or rental of exercise cycles, water purifiers,               been proven safe and effective for a specific disease or
    hypo-allergenic pillows, mattresses or waterbeds,                     approved for a mode of treatment by the Food and
    whirlpool or swimming pools, exercise and massage                     Drug Administration (FDA) and the National Institutes of
    equipment, central or unit air conditioners, air purifiers,           Health (NIH); needles, syringes and other injectable aids
    humidifiers, dehumidifiers, escalators, elevators, ramps,             (except for diabetic supplies.); drugs related to the
    stair glides, emergency alert equipment, handrails, heat              treatment of non-covered services; and drugs related to
    appliances, improvements made to a member’s house                     contraception (unless covered by a prescription drug
    or place of business and adjustments made to vehicles.                rider), the treatment of infertility, and performance
                                                                          enhancing steroids.
I   Educational services and treatment of behavioral
    disorders and services for remedial education including           I   Inpatient care for serious mental illness which is not
    evaluation or treatment of learning disabilities, minimal             provided in a hospital or mental health treatment
    brain dysfunction, developmental and learning                         facility; non-medical ancillary services and rehabilitation
    disorders, behavioral training, and cognitive                         services in excess of the number of days described in
    rehabilitation. This includes services, treatment or                  the Schedule of Benefits for serious mental illness.
    educational testing and training related to behavioral            I   Inpatient treatment for mental or behavioral conditions,
    (conduct) problems, learning disabilities, or                         except for serious mental illness (unless covered by a
    developmental delays. Special education, including                    rider to your plan).
    lessons in sign language to instruct a member, whose
    ability to speak has been lost or impaired, to function
    without that ability, are not covered.
I   Military service related diseases, disabilities or injuries for           3. services or supplies furnished solely because the
    which the member is legally entitled to receive                              member is an inpatient on any day in which the
    treatment at government facilities and which facilities                      member’s disease or injury could safely and
    are reasonably available to the member.                                      effectively be diagnosed or treated while the
I   Missed appointment charges.                                                  member is not an inpatient;
I   Non-diagnostic and non-medical/surgical treatment of                      4. services or supplies furnished in a particular setting
    temporomandibular joint disorder (TMJ).                                      that could safely and effectively be furnished in a
                                                                                 physician’s or a dentist’s office or other less costly
I   Oral or topical drugs used for sexual dysfunction or
                                                                                 setting consistent with the applicable standard of
I   Orthoptic therapy (vision exercises).
                                                                          I   Services performed by a relative of a member for which,
I   Orthotics.                                                                in the absence of any health benefits coverage, no
I   Outpatient medical consumable or disposable supplies                      charge would be made.
    such as syringes, incontinence pads, elastic stockings,               I   Services rendered for the treatment of delays in speech
    and reagent strips. This exclusion does not apply to                      development, unless resulting from disease, injury, or
    diabetic supplies.                                                        congenital defects.
I   Performance, athletic performance or lifestyle                        I   Services required by third parties, including but not
    enhancement drugs and supplies.                                           limited to, physical examinations, diagnostic services and
I   Personal comfort or convenience items.                                    immunizations in connection with obtaining or
I   Prescription or non-prescription drugs and medicines,                     continuing employment, insurance, travel, school
    except as provided on an inpatient basis (unless covered                  admissions or attendance, including examinations
    by a prescription drug rider). This exclusion does not                    required to participate in athletics, except when such
    apply to diabetes supplies, including but not limited to                  examinations are considered to be part of an
    insulin.                                                                  appropriate schedule of wellness services.
I   Private duty or special nursing care (unless medically                I   Specific non-standard allergy services and supplies,
    necessary and pre-authorized by Aetna).                                   including but not limited to, skin titration (wrinkle
                                                                              method), cytotoxicity testing (Bryan’s Test), treatment of
I   Recreational, educational, and sleep therapy, including
                                                                              non-specific candida sensitivity, and urine autoinjections.
    any related diagnostic testing.
                                                                          I   Special medical reports, including those not directly
I   Religious, marital and sex counseling, including services
                                                                              related to treatment of the member (i.e., reports
    and treatment related to religious counseling,
                                                                              prepared in connection with litigation).
    marital/relationship counseling, and sex therapy.
                                                                          I   Spinal manipulation for subluxation.
I   Reversal of voluntary sterilizations.
                                                                          I   Surgical operations, procedures or treatment of obesity.
I   Routine foot/hand care.
                                                                          I   Therapy or rehabilitation as follows: primal therapy
I   Services for which a member is not legally obligated to
                                                                              (intense non-verbal expression of emotion expected to
    pay in the absence of this coverage.
                                                                              result in improvement or cure of psychological
I   Services for the treatment of sexual dysfunctions or                      symptoms), chelation therapy (removal of excessive
    inadequacies, including therapy, supplies, or counseling                  heavy metal ions from the body), rolfing, psychodrama,
    for sexual dysfunctions or inadequacies that do not                       megavitamin therapy, purging, bioenergetic therapy,
    have a physiological or organic basis.                                    vision perception training, carbon dioxide and other
I   Services or supplies as follows:                                          therapy or rehabilitation not supported by medical and
    1. services or supplies that do not require the technical                 scientific evidence. This exclusion does not apply to
       skills of a medical, mental health or a dental                         rehabilitative services such as physical, speech and
       professional;                                                          occupational therapy.
    2. services or supplies furnished mainly for the personal             I   Transsexual surgery, sex change or transformation,
       comfort or convenience of the member, or any                           including any procedure or treatment or related service
       person who cares for the member, or any person                         designed to alter a Member’s physical characteristics
       who is part of the member’s family, or any provider;                   from the Member’s biologically determined sex to those
                                                                              of another sex, regardless of any diagnosis of gender
                                                                              role or psychosexual orientation problems.

I   Treatment in a federal, state, or governmental entity,             Discharge Planning
    including care and treatment provided in a non-                    Discharge planning may be initiated at any stage of the
    participating hospital owned or operated by any federal,           patient management process and begins immediately
    state or other governmental entity, except to the extent           upon identification of post-discharge needs during
    required by applicable laws.                                       precertification or concurrent review. The discharge plan
I   Treatment of mental retardation, defects, and                      may include initiation of a variety of services/benefits to be
    deficiencies.                                                      utilized by the member upon discharge from an inpatient
I   Treatment of occupational injuries and occupational                stay.
    diseases.                                                          Retrospective Review
I   Unauthorized services, including any non-emergency                 Retrospective review is a review performed for the first
    service obtained by or on behalf of a member without               time after the member has received the treatment in
    prior referral by the member’s PCP or certification by             question. Retrospective review does not include
    HMO.                                                               subsequent review of services for which prospective or
I   Vision care services and supplies, including orthoptics (a         concurrent reviews for medical necessity and
    technique of eye exercises designed to correct the visual          appropriateness were previously conducted. The purpose
    axes of eyes not properly coordinated for binocular                of retrospective review is to determine coverage and
    vision) and radial keratotomy, including related                   payment of such claims under the plan, retrospectively
    procedures designed to surgically correct refractive               analyze potential quality and utilization issues, initiate
    errors.                                                            appropriate follow-up action based on quality or utilization
                                                                       issues, and review all appeals of decisions for coverage and
I   Weight reduction programs or dietary supplements.
                                                                       payment of such healthcare services.
                                                                       Prescription Drugs
Precertification and Other Review
Processes                                                              If your plan covers outpatient prescription drugs, certain
                                                                       drugs may require precertification or step therapy. Step
Precertification                                                       therapy is a form of precertification that requires a trial of
For those services that do not allow direct access, you must           one or more “prerequisite therapy” medications before a
first obtain a referral from your PCP. Your doctor also may            “step therapy” medication will be covered. If it is
be required to obtain prior approval of coverage for certain           medically necessary for a member to use a step therapy
services. This is called “precertification.” It is also referred       medication initially, the member’s physician can request
to as “prospective review”. You should ask your PCP or                 coverage of such drug as a formulary exception. Refer to
Aetna whether precertification is necessary for any covered            your plan documents and formulary guide or contact
services. Failure to obtain precertification where required            Member Services for questions on coverage. You may also
may cause you to be financially responsible for those                  contact Member Services to determine if a specific
services.                                                              prescription drug is included on the formulary, or visit our
If your plan covers out-of-network benefits and you may                website at
self-refer for covered services, it is your responsibility to          What Happens If A Provider Leaves the Health Plan
contact Aetna to precertify those services that require                If your physician or provider leaves the plan, you may be
precertification.                                                      able to continue to see that physician or provider during a
Concurrent Review                                                      transitional period`. For information on continuity of care
Aetna also reviews certain services at the time of delivery            in these situations, please refer to your Certificate of
(“concurrent review”) to assess the necessity for continued            Coverage or call Member Services at the toll-free number
stay, level of care, and quality of care for members                   on your ID card.
receiving inpatient services. All inpatient services extending
beyond the initial certification period require concurrent
review. Concurrent review is the responsibility of Aetna
and the provider.
COMPLAINTS, APPEALS AND                                            Members may obtain additional information from the
INDEPENDENT REVIEW                                                 Texas Department of Insurance regarding their rights. The
                                                                   website for the Texas Department of Insurance is
Complaint Process
                                                          Their toll-free telephone number is
Our complaint resolution process is designed to address            1-800-578-4677.
member coverage issues, complaints and problems. A
                                                                   Independent Review of Medical Necessity Appeals
member, a member’s physician, provider or a member’s
authorized representative may begin this review process. If        Aetna participates in the Texas independent review
you have a coverage issue or other problem, call the               organization (IRO) process. You may request IRO review
Member Services toll-free number on your ID card, contact          upon receiving a denial based on medical necessity and
them on-line at, or write to them at:                exhausting the internal appeal process (except in cases of a
                                                                   life-threatening condition, where it is not necessary to
                                                                   exhaust the internal appeals process before requesting IRO
  Regional Correspondence Unit
                                                                   review, as discussed in the “Appeals Process” section
  P.O. Box 150927
                                                                   above). The process for IRO review is defined by Texas law
  Arlington, TX 76015
                                                                   and is described in your plan documents. You will also
A Member Services representative will address your                 receive information on the independent review process
concern. If you are dissatisfied with the outcome of your          when you initiate an appeal in Aetna’s internal complaint
initial contact, you may file a formal complaint. Upon             and appeals process. You may also call the Member
request, the Office of the Ombudsman can assist members            Services toll-free number on your ID card or the Texas
in understanding the complaint process or filing a                 Department of Insurance for further information about the
complaint. You can review your plan documents for more             IRO procedures.
information on the complaint process. If you are not
                                                                   Aetna is interested in hearing all comments, questions,
satisfied after filing a formal complaint, you may appeal
                                                                   complaints or appeals from customers, members,
the decision as described below.
                                                                   physicians and providers, and does not retaliate against
Appeals Process                                                    any of those individuals or groups for initiating a complaint
Upon receipt of a written appeal, Aetna will send an               or appeal.
acknowledgment letter describing the applicable appeal             Binding Arbitration
procedures, including the member’s right to request
                                                                   Most of our plans contain the following binding arbitration
assistance from the Office of the Ombudsman. Appeals
that do not involve medical necessity issues will be
addressed by an appeal panel. The member may appear                   HMO, Contract Holder and Member may agree to
in person or by telephone before the appeal panel or                  binding arbitration to resolve any controversy, dispute or
address the issues in writing. Appeals of medical necessity           claim between them arising out of or relating to this
denials will be reviewed by a Texas-licensed physician who            Certificate, whether stated in tort, contract, statute,
was not involved in the original decision. If Aetna                   claim for benefits, bad faith, professional liability or
determines that a service or supply is not medically                  otherwise (“Claim”). Said binding arbitration shall be
necessary for the member, the member (or their authorized             administered pursuant to the Texas Arbitration Act
representative) may appeal to the Texas independent                   before a sole arbitrator (“Arbitrator”). Judgment on the
review organization (IRO) after exhausting the internal               award rendered by the Arbitrator (“Award”) may be
review process. If you have a life-threatening condition              entered by any court having jurisdiction thereof. If
(e.g., a disease or condition in which death is probable              administrator declines to oversee the case and the
unless the course of the disease or condition is                      parties do not agree on an alternative administrator, a
interrupted), you may appeal a medical necessity denial               sole neutral Arbitrator shall be appointed upon petition
immediately to an IRO, as described below, without first              to a court having jurisdiction. Should the parties agree
exhausting this internal appeal process.                              to resolve their controversy, dispute or claim through
                                                                      binding arbitration, said arbitration shall be held in lieu
Aetna will notify the appealing party of the outcome of an
                                                                      of any and all other legal remedies and rights that the
appeal, including information on assistance available from
                                                                      parties may have regarding their controversy, dispute or
the Office of the Ombudsman, within 30 days of our
                                                                      claim, unless otherwise required by law.
receipt of all information necessary to complete the
appeal.                                                               If the parties do not agree to binding arbitration,
                                                                      nothing herein shall limit any legal right or remedy that
                                                                      the parties may otherwise have.

Check your plan documents to determine if your plan                    PCPs who are part of a limited provider network will have
contains this provision.                                               that designation shown in the directory immediately
                                                                       following their name (e.g., Dr. John Smith, XYZ IPA). If you
Current List of Physicians and Providers                               have questions about whether a PCP is a member of a
                                                                       limited provider network, please call the Member Services
Please refer to your Physician & Hospital Directory for a list
                                                                       toll-free telephone number on your ID card.
of physicians and other providers who participate in your
plan. If you do not have a directory, you may request one              Female members: In selecting a PCP, remember that your
from Aetna by calling 1-888-982-3862. You can also refer               PCP’s limited provider network affects your choice of an
to our on-line provider directory, DocFind®, at                        Ob/Gyn. You have the right to designate an Ob/Gyn to for a current list of participating                      whom you have access without first obtaining referral from
physicians and providers. Your mental health providers are             a PCP. However, the designated Ob/Gyn must belong to
listed in this directory. If you have this covered benefit, you        the same limited provider network as your PCP. This is
may contact your PCP or call 1-800-424-3803 to find out                another reason to be sure your PCP’s limited provider
how to access mental health services.                                  network includes the specialist (particularly the Ob/Gyn)
                                                                       and hospitals you prefer. You do not have to designate an
While the provider directory is believed to be accurate as of
                                                                       Ob/Gyn; instead, you may elect to receive Ob/Gyn services
the print date, it is subject to change without notice.
                                                                       from your PCP.
Consult Aetna’s on-line provider directory on our website
at for the most current provider listings.               If medically necessary covered services are not available
The on-line provider directory is updated at least weekly.             within Aetna’s network or within your PCP’s limited
Participating providers are independent contractors in                 provider network, you have the right to a referral to a
private practice and are neither employees nor agents of               specialist or provider outside Aetna’s network of physicians
Aetna or its affiliates. The availability of any particular            or providers, and outside the limited provider network to
provider cannot be guaranteed for referred or in-network               which your PCP belongs.
benefits, and provider network composition is subject to               If medically necessary covered services you wish to receive
change without notice. In addition, not every provider                 are available through your limited provider network, but
listed in the directory will be accepting new patients.                you want to receive these services from an Aetna network
Although Aetna has identified providers who were not                   provider who is not within your PCP’s limited provider
accepting patients as known to Aetna at the time the                   network, you may change your PCP in order to select a
provider directory was created, the status of a provider’s             PCP within the same limited provider network from which
practice may have changed. For the most current                        you want to receive medically necessary covered services.
information, please contact the selected physician or                  Please also see the “Prior Authorization, Precertification
Member Services at the toll-free number on your ID card.               and Other Review Processes” and “Emergency Care”
Your PCP may be part of a practice group or association of             sections for additional information on accessing care.
health professionals (often referred to as a “limited
provider network”) who work together to provide a full                 Physician Compensation
range of health care services. That means when you
                                                                       If you have any question about how your physician or
choose your PCP, in some cases, you are also choosing a
                                                                       other health care providers are compensated, you should
limited provider network. In most instances, you will not
                                                                       call the Aetna toll-free number for Member Services listed
be allowed to receive services from any physician or
                                                                       on your ID card. Aetna encourages you to discuss this
provider who is not also part of your PCP’s limited provider
                                                                       issue with your physician or other provider.
network. You will not be able to select any physician or
provider outside of your PCP’s limited provider network,               One of the goals of managed care is to reduce and control
even though that physician or provider appears in the                  the costs of health care. Financial incentives in
directory. To the extent it is available, your care will be            compensation arrangements with physicians and health
provided or arranged for within your PCP’s limited provider            care providers are one method by which Aetna attempts to
network, so make sure your PCP’s limited provider network              reduce and control the costs of health care.
includes the specialists and hospitals you prefer.                     Appropriate financial incentives are intended to:
                                                                       I   reduce waste in the application of medical resources;
                                                                       I   eliminate inefficiencies which may lead to artificial
                                                                           inflation of health care costs;
                                                                       I   encourage physicians and health care providers to
                                                                           practice preventive medicine and focus on improving
                                                                           the long-term health of patients;
I   direct attention to patient satisfaction; and                      Claims Payment for Non-participating
I   improve the efficient delivery of quality health care              Providers and Use of Claims Software
    services without compromising the quality and integrity            If your plan provides coverage for services rendered by
    of the physician-patient relationship.                             non-participating providers, you should be aware that
Only appropriate financial incentives will be used to                  Aetna determines the usual, customary and reasonable fee
compensate physicians and providers treating Aetna                     for a provider by referring to commercially available data
members.                                                               reflecting the customary amount paid to most providers for
Capitation is an example of a financial incentive                      a given service in that geographic area. If such data is not
arrangement that Aetna may use to compensate                           commercially available, our determination may be based
physicians and other health care providers. Under                      upon our own data or other sources. Aetna may also use
capitation, a physician, physician group, independent                  computer software (including ClaimCheck) and other tools
practice association, or other health care provider is paid a          to take into account factors such as the complexity,
predetermined set amount to cover all costs of providing               amount of time needed and manner of billing. You may
certain medically necessary benefits to members whether                be responsible for any charges Aetna determines are not
or not the actual costs of providing those medically                   covered under your plan.
necessary covered benefits is greater or lesser than the pre-
determined set amount. In its capitation arrangements                  Service Area
with an individual physician or provider, Aetna provides               A service area map is contained on the back cover of the
capitation payments only for those services the physician or           Physician & Hospital directory. If you have questions about
provider provides to you. However, in a capitation                     our service area, please call Member Services at 1-888-
arrangement with a group of physicians or providers, also              982-3862.
known as a “delegated entity”, Aetna may provide
capitation payments for additional health care services such           Confidentiality and Privacy Notices
as hospitalization, use of specialists, tests, and prescription
drugs. Under either capitation arrangement, your                       Aetna considers personal information to be confidential
physician or provider has a financial incentive to reduce              and has policies and procedures in place to protect it
and control the costs of providing medical care.                       against unlawful use and disclosure. By “personal
                                                                       information,” we mean information that relates to a
Texas law prohibits financial incentives that act directly or          member’s physical or mental health or condition, the
indirectly as an inducement to limit medically necessary               provision of health care to the member, or payment for the
services. An improperly used incentive may encourage a                 provision of health care to the member. Personal
physician to provide a patient with a less effective                   information does not include publicly available information
treatment because it is less expensive.                                or information that is available or reported in a
Aetna will not improperly use incentives to compensate                 summarized or aggregate fashion but does not identify the
physicians and providers for treatments and services                   member.
provided to Aetna members.                                             When necessary or appropriate for your care or treatment,
If you are considering enrolling in our plan, you are entitled         the operation of our health plans, or other related
to ask if the plan, or any provider group serving Aetna                activities, we use personal information internally, share it
members, has compensation arrangements with                            with our affiliates, and disclose it to health care providers
participating physicians and providers that can create a               (doctors, dentists, pharmacies, hospitals and other
financial incentive to reduce or control the costs of                  caregivers), payors (health care provider organizations,
providing medically necessary covered services. A summary              employers who sponsor self-funded health plans or who
of the compensation arrangements known to Aetna                        share responsibility for the payment of benefits, and others
relating to a particular physician or provider will be made            who may be financially responsible for payment for the
available upon request by calling the Member Services                  services or benefits you receive under your plan), other
telephone number on your ID card. Alternatively, you may               insurers, third-party administrators, vendors, consultants,
contact the provider group directly to find out about                  government authorities, and their respective agents.
compensation arrangements between the provider group
and any participating physician or provider. You may also
wish to ask your physician about what financial incentive
arrangements are included in his or her compensation.

These parties are required to keep personal information
confidential as provided by applicable law. 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:
I   claims payment;
I   utilization review and management;
I   medical necessity reviews;
I   coordination of care and benefits;
I   preventive health;
I   early detection;
I   disease and case management;
I   quality assessment and improvement activities;
I   auditing and antifraud activities;
I   performance measurement and outcomes assessment;
    health claims analysis and reporting;
I   health services research;
I   data and information systems management;
I   compliance with legal and regulatory requirements;
I   formulary management;
I   litigation proceedings;
I   transfer of policies or contracts to and from other
    insurers, HMOs and third party administrators;
    underwriting activities; and
I   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 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 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 hard copy of our Notice of Privacy Practices,
which describes in greater detail our practices concerning
use and disclosure of personal information, please write to
Aetna’s Legal Support Services Department at 151
Farmington Avenue, W121, Hartford, CT 06156. You can
also visit our Internet site at You can
link directly to the Notice of Privacy Practices by selecting
the “Privacy Notices” link at the bottom of the page.
This notice is to advise you of certain coverage and/or             This benefit does not require a covered female who is
benefits provided by your contract with Aetna. If you have          eligible for maternity/childbirth benefits to (a) give birth in
any questions concerning this notice, please call us at the         a hospital or other health care facility or (b) remain in a
Member Services number on the back of your ID card, or              hospital or other health care facility for the minimum
write us at the following address:                                  number of hours following birth of the child.
  Aetna Patient Management                                          If a covered mother or her newborn child is discharged
  P.O. Box 569440                                                   before the 48 or 96 hours has expired, we will provide
  Dallas, Texas 75356-9440                                          coverage for postdelivery care. Postdelivery care includes
                                                                    parent education, assistance and training in breast-feeding
Coverage for Tests for Detection of                                 and bottle-feeding and the performance of any necessary
Colorectal Cancer                                                   and appropriate clinical tests. Care will be provided by a
                                                                    physician, registered nurse or other appropriate licensed
Benefits are provided, for each person enrolled in the plan         health care provider, and the mother will have the option
who is 50 years of age or older and at normal risk for              of receiving the care at her home, the health care
developing colon cancer, for expenses incurred in                   provider’s office or a health care facility.
conducting a medically recognized screening examination
for the detection of colorectal cancer. Benefits include the        Because we provide in-home postdelivery care, we are not
covered person’s choice of:                                         required to provide the minimum number of hours
                                                                    outlined above unless (a) the mother’s or child’s physician
  (a) a fecal occult blood test performed annually and a            determines the inpatient care is medically necessary or (b)
      flexible sigmoidoscopy performed every five years, or         the mother requests the inpatient stay.
  (b) a colonoscopy performed every 10 years.                       Prohibitions: We may not (a) modify the terms of this
Form Number 1467 Colorectal Cancer Screening                        coverage based on any covered person requesting less
                                                                    than the minimum coverage required; (b) offer the mother
Prostate Cancer Screening                                           financial incentives or other compensation for waiver of
Benefits are provided for each covered male for an annual           the minimum number of hours required; (c) refuse to
medically recognized diagnostic examination for the                 accept a physician’s recommendation for a specified period
detection of prostate cancer. Benefits include a:                   of inpatient care made in consultation with the mother if
                                                                    the period recommended by the physician does not exceed
  (a) Physical examination for the detection of prostate
                                                                    guidelines for prenatal care developed by nationally
                                                                    recognized professional associations of obstetricians and
  (b) Prostate-specific antigen test for each covered male          gynecologists or pediatricians; (d) reduce payments or
      who is at least:                                              reimbursements below the usual and customary rate; or (f)
      (1) 50 years of age                                           penalize a physician for recommending inpatient care for
      (2) 40 years of age with a family history of prostate         the mother or the newborn child.
          cancer or other prostate cancer risk factor.              Form Number 102 Maternity
Form Number 258 Prostate
                                                                    Breast Reconstruction
Inpatient Stay Following Birth of a Child                           Coverage and/or benefits are provided to each covered
For each person covered for maternity/childbirth benefits,          person for reconstructive surgery after mastectomy,
we will provide inpatient care for the mother and her               including:
newborn child in a health care facility for a minimum of:              (a) All stages of the reconstruction of the breast on
  (a) 48 hours following an uncomplicated vaginal                          which mastectomy has been performed.
      delivery.                                                        (b) Surgery and reconstruction of the other breast to
  (b) 96 hours following an uncomplicated delivery by                      achieve a symmetrical appearance.
      cesarean section.                                                (c) Prostheses and treatment of physical complications,
                                                                           including lymphedemas, at all stages of mastectomy.
The coverage and/or benefits must be provided in a
manner to be appropriate in consultation with the covered
person and the attending physician.
Prohibitions: We may not (a) offer the covered person a
financial incentive to forego breast reconstruction or waive
the coverage and/or benefits shown above; (b) condition,
limit, or deny any covered person’s eligibility or continued
eligibility to enroll in the plan or fail to renew this plan
solely to avoid providing the coverage and/or benefits
shown above; or (c) reduce or limit the amount paid to the
physician or provider, nor otherwise penalize, or provide a
financial incentive to induce the physician or provider to
provide care to a covered person in a manner inconsistent
with the coverage and/or benefits shown above.
Form Number 1764 Reconstructive Surgery After
Mastectomy — Enrollment

Mastectomy or Lymph Node Dissection
Minimum Inpatient Stay
If due to treatment of breast cancer, any person covered by
this plan has either a mastectomy or a lymph node
dissection, this plan will provide coverage for inpatient care
for a minimum of:
   (a) 48 hours following a mastectomy, and
   (b) 24 hours following a lymph node dissection.
The minimum number of inpatient hours is not required if
the individual receiving the treatment and the attending
physician determine that a shorter period of inpatient care
is appropriate.
Prohibitions: We may not (a) deny any covered person
eligibility or continued eligibility or fail to renew this plan
solely to avoid providing the minimum inpatient hours; (b)
provide money payments or rebates to encourage any
covered person to accept less than the minimum inpatient
hours; (c) reduce or limit the amount paid to the attending
physician, or otherwise penalize the physician, because the
physician required a covered person to receive the
minimum inpatient hours; or (d) provide financial or other
incentives to the attending physician to encourage the
physician to provide care that is less than the minimum
Form Number 349 Mastectomy

Health Insurance Portability and
Accountability Act Member Notice*
The following information is provided to inform the member of certain provisions
contained in the Group Health Plan, and related procedures that may be utilized by the
member in accordance with Federal law.

Pre-existing Conditions Exclusion                                                Please note: If a state law mandates a gap period greater
Provision (only for plans containing such                                        than 90 days, that longer gap period will be used to
                                                                                 determine creditable coverage.
                                                                                 If you have any questions regarding the determination of
This is to advise you that a pre-existing conditions exclusion
                                                                                 whether or not a pre-existing conditions exclusion applies
period may apply to you, if a pre-existing conditions
                                                                                 to you, please call the Member Services telephone number
exclusion provision is included in the group plan that you
                                                                                 on your ID card.
are or become covered under. If your plan contains a pre-
existing conditions exclusion, such exclusion may be
waived for you if you have prior creditable coverage.                            Providing Proof of Creditable Coverage
                                                                                 Generally, you will have received a Certification Of Prior
Creditable Coverage                                                              Group Health Plan Coverage from your prior medical
                                                                                 plan as proof of your prior coverage. You should retain
Creditable coverage includes coverage under a group
                                                                                 that certification until you submit a medical claim. When a
health plan (including a governmental or church plan),
                                                                                 claim for treatment of a potential pre-existing condition is
health insurance coverage (either group or individual
                                                                                 received, the claim office will request from you that
insurance), Medicare, Medicaid, militarysponsored health
                                                                                 Certification Of Prior Group Health Plan Coverage,
care (TRICARE), a program of the Indian Health Service, a
                                                                                 which will be used to determine if you have creditable
State health benefit risk pool, the FEHBP, a public health
                                                                                 coverage at that time.
plan as defined in the regulations, and any health benefit
plan under section 5(c) of the Peace Corps Act and short-                        You may request a Certification Of Prior Group Health Plan
term limited duration insurance. Not included as creditable                      Coverage from your prior carrier(s) with whom you had
coverage is any coverage that is exempt from the law (e.g.,                      coverage within the past two years. Our service center can
dental only coverage or dental coverage that is provided in                      assist you with this and can provide you with the type of
a separate plan or even if in the same plan as medical, is                       information that you will need to request from your prior
separately elected and results in additional premium).                           carrier.
If you had prior creditable coverage within the 90 days                          The service center may also request information from you
immediately before the date you enrolled under this plan,                        regarding any pre-existing condition for which you may
then the pre-existing conditions exclusion in your plan, if                      have been treated in the past, and other information that
any, will be waived. The determination of the 90-day                             will allow them to determine if you have creditable
period will not include any waiting period that may be                           coverage.
imposed by your employer before you are eligible for
If you had no prior creditable coverage within the 90
days prior to your enrollment date (either because you had
no prior coverage or because there was more than a 90-
day gap from the date your prior coverage terminated to
your enrollment date), we will apply your plan’s pre-
existing conditions exclusion (to a maximum period of 12

* While this member notice is believed to be accurate as of the print date, it is subject to change. Please contact the Member Services Department if
  you have any questions.
Special Enrollment Periods                                          For Certain Dependent Beneficiaries
Due to Loss of Coverage                                             If your Group Health Plan offers dependent coverage, it is
If you are eligible for coverage under your employer’s              required to offer a dependent special enrollment period for
medical plan but do/did not enroll in that medical plan             persons becoming a dependent through marriage, birth, or
because you had other medical coverage, and you lose                adoption or placement for adoption. The dependent
that other medical coverage, you will be allowed to enroll          special enrollment period will last for 31 days from the
in the current medical plan during special enrollment               date of the marriage, birth, adoption or placement for
periods after your initial eligibility period, if certain           adoption. The dependent may be enrolled during that time
conditions are met. These Special Enrollment Rules apply to         as a dependent of the employee. If the employee is eligible
employees and/or dependents who are eligible, but not               for enrollment, but not enrolled, the employee may also
enrolled for coverage, under the terms of the plan.                 enroll at this time. In the case of the birth or adoption of a
                                                                    child, the spouse of the individual also may be enrolled as
An employee or dependent is eligible to enroll during a             a dependent of the employee if the spouse is otherwise
special enrollment period if each of the following                  eligible for coverage but not already enrolled. If an
conditions are met:                                                 employee seeks to enroll a dependent during the special
I   When you declined enrollment for you or your                    enrollment period, the coverage would become effective
    dependent, you stated in writing that coverage under            as of the date of birth, of adoption or placement for
    another group health plan or other health insurance             adoption, or marriage.
    was the reason for declining enrollment, if the employer        Special Enrollment Rules
    required such written notice and you were given notice
    of the requirement and the consequences of not                  To qualify for the special enrollment, individuals who meet
    providing the statement; and                                    the above requirements must submit a signed request for
                                                                    enrollment no later than 31 days after one of the events
I   When you declined enrollment for you or your                    described above. The effective date of coverage for
    dependent, you or your dependent had COBRA                      individuals who lost coverage will be the date of the
    continuation coverage under another plan and that               qualifying event. If you seek to enroll a dependent during
    COBRA continuation coverage has since been                      the special enrollment period, coverage for your
    exhausted,                                                      dependent (and for you, if also enrolling) will become
    or                                                              effective as of the date that the qualifying event occurred,
    If the other coverage that applied to you or your               (for marriage, as of the enrollment date) once the
    dependent when enrollment was declined was not                  completed request for enrollment is received.
    under a COBRA continuation provision, either the other
    coverage has been terminated as a result of the loss of
    eligibility or employer contributions toward that
    coverage have been terminated. Loss of eligibility
    includes a loss of coverage as a result of legal
    separation, divorce, death, termination of employment,
    or reduction in hours of employment.

As of 7/1/2005 this addendum replaces the Health Insurance Portability and
Accountability Act Member Notice that appears elsewhere in this disclosure. See your
Benefit Summary for information regarding preexisting conditions exclusions.
The following information is provided to inform the member of certain provisions contained in the Group Health Plan, and
related procedures that may be utilized by the member in accordance with federal law.

Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or
group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents
lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage).
However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the
employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able
to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth,
adoption or placement for adoption.
To request special enrollment or obtain more information, contact your benefits administrator.

Request for Certificate of Creditable Coverage
Members of insured plan sponsors and members of self insured plan sponsors who have contracted with us to provide
Certificates of Prior Health Coverage have the option to request a certificate. This applies to terminated members, and it
applies to members who are currently active but who would like a certificate to verify their status. Terminated members can
request a certificate for up to 24 months following the date of their termination. Active member can request a certificate at
any time. To request a Certificate of Prior Health Coverage, please contact Member Services at the telephone number on the
back of your ID card.

*While this Member Notice is believed to be accurate as of the publication date, it is subject to change. Please contact the Member Services department
 if you have any questions.
00.28.317.1 (7/05)                                                        18
Notice to Members
While this information is believed to be accurate as of the           Aetna is the brand name used for products and services
print date, it is subject to change.                                  provided by one or more of the Aetna group of subsidiary
This material is for informational purposes only and is               companies. In-network and out-of-network referred
neither an offer of coverage nor medical advice. It contains          benefits are underwritten by Aetna Health Inc. Self-referred
only a partial, general description of plan benefits or               benefits are underwritten by Corporate Health Insurance
programs and does not constitute a contract. Aetna                    Company. For self-funded accounts, benefits coverage
arranges for the provision of health care services. However,          offered by your employer, with administrative services only
Aetna itself is not a provider of health care services and            provided by Aetna Life Insurance Company.
therefore, cannot guarantee any results or outcomes.
Consult the plan documents [Group Agreement, Group
Insurance Certificate, Schedule of Benefits, Certificate of
Coverage, Group Policy] to determine governing
contractual provisions, including procedures, exclusions
and limitations relating to the plan. The availability of a
plan or program may vary by geographic service area and
by plan design. These plans contain exclusions and some
benefits are subject to limitations or visit maximums.
With the exception of Aetna Rx Home Delivery®, all
participating physicians, hospitals and other health care
providers are independent contractors and are neither
agents nor employees of Aetna. Aetna Rx Home Delivery,
LLC. is a subsidiary of Aetna Inc. The availability of any
particular provider cannot be guaranteed, and provider
network composition is subject to change. Notice of the
change shall be provided in accordance with applicable
state law. Certain primary care physicians are affiliated with
integrated delivery systems or other provider groups (such
as independent practice associations and physician-hospital
organizations), and members who select these providers
will generally be referred to specialists and hospitals within
those systems or groups. However, if a system or group
does not include a provider qualified to meet member’s
medical needs, member may request to have services
provided by nonsystem or nongroup providers. Member’s
request will be reviewed and will require prior
authorization from the system or group and/or Aetna to be
a covered benefit.
The NCQA Accreditation Seal is a recognized symbol of
quality. NCQA recognition seals appear in the provider
directory next to those providers who have been duly
recognized. NCQA provider recognitions are subject to
For up-to-date information, please visit our DocFind®
online provider directory at or visit the
NCQA’s new top-level recognition listing at


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