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					Effective January 1, 2010
Contents
Introduction ............................................................................................................. 1
     Terms You Need To Know .............................................................................................................. 1
Summary of Benefits ................................................................................................ 2
How the Plan Works.................................................................................................. 6
     In-Network Care ................................................................................................................................. 6
     Out-of-Network Care......................................................................................................................... 7
     Sharing the Cost ................................................................................................................................ 8
What the Plan Covers................................................................................................ 9
     Wellness Care ..................................................................................................................................... 9
     Outpatient Care.................................................................................................................................10
     Family Planning .................................................................................................................................11
     Inpatient Care ....................................................................................................................................13
     Transplant Services .........................................................................................................................13
     Hospice Care .....................................................................................................................................15
     Home Health Care ............................................................................................................................15
     Emergency Care................................................................................................................................16
     Ambulance ..........................................................................................................................................16
     Mental Health and Substance Abuse Care...............................................................................16
     Oral Surgery .......................................................................................................................................17
     Temporomandibular Joint Dysfunction (TMJ) Disorder .......................................................18
     Other Covered Expenses ...............................................................................................................19
Prescription Drugs ................................................................................................. 20
     Formulary Drugs................................................................................................................................20
     Retail Pharmacy................................................................................................................................20
     Mail Order ...........................................................................................................................................21
     Precertification .................................................................................................................................21
     Specialty Pharmacy .........................................................................................................................23
     Covered Drugs ...................................................................................................................................24
     What the Prescription Drug Plan Does Not Cover ..................................................................24
What the Plan Does Not Cover.................................................................................. 26
Claims .................................................................................................................. 30
     Keeping Records of Expenses .....................................................................................................30
     Filing Claims ......................................................................................................................................30
     Physical Exams .................................................................................................................................30
     Legal Action .......................................................................................................................................30
     Claim Processing ..............................................................................................................................31
     Appeals ................................................................................................................................................32
     Claim Fiduciary .................................................................................................................................33
     Subrogation/Reimbursement ........................................................................................................34
Glossary ............................................................................................................... 37
Introduction
This booklet describes the main features of the Aetna Select Plan. Here you’ll find information
about how the plan works, what is covered, what is not covered and how to file a claim.
This booklet is a portion of the Summary Plan Description (SPD) required by ERISA. Check
benefits information in HR//direct online for more SPD information, including:
        Eligibility, enrollment and effective dates;
        When coverage begins and ends;
        Continuation of coverage after benefits terminate;
        Coordination of benefits; and
        Plan administration.
Bayer Corporation hopes to continue this plan indefinitely but, as with all group plans, it may be
changed or discontinued for all or any class of employees.


Words and phrases that appear in bold type are defined in the Glossary at the back of this book.



Terms You Need To Know
You need to understand the following terms to get the most out of your medical plan. Refer to the
Glossary for full definitions.
Negotiated Charge: In-network providers have agreed to charge no more than the negotiated
charge for a service or supply that is covered by the plan. You are not responsible for amounts
that exceed the negotiated charge when you obtain care from an in-network provider.
Necessary Services and Supplies: The plan pays benefits only for medically necessary
services and supplies.
A necessary service is one that a physician, using prudent clinical judgment, would provide to a
patient to evaluate, diagnose or treat an illness, injury, disease or its symptoms.
Non-Occupational Coverage: The medical plan covers only expenses related to non-
occupational injuries and non-occupational diseases.




                                                   1                                 Introduction
Summary of Benefits
The chart in this section provides a summary of your benefits under the plan.
         The first part of the chart shows information about cost sharing features and certain
         benefit limits.
         The second part of the chart lists the major types of expenses covered under the plan
         and shows how benefits are paid for each type of expense.
Here are some important points to remember about your benefits:
1. The plan pays benefits only for necessary care.
    “Necessary” means the care is appropriate for the diagnosis, care or treatment of the disease
    or injury involved. Refer to the Glossary for a full definition of “necessary.”
2. The plan pays benefits for in-network care only.
    With the exception of emergency care, the plan’s coverage is limited to services and supplies
    you receive from in-network providers. Out-of-network care is not covered.
3. You must have a referral from your PCP before visiting a specialist or other health care
   provider in the network. Without the referral, the care is not covered.


                   Cost Sharing                                        Benefit Level
COPAYMENTS                                                                 You Pay
PCP Office Visit                                                       $15 copay per visit
Specialist Office Visit                                                $20 copay per visit
Hospital Admission                                                 $150 copay per admission
Emergency Room Visit                                                   $50 copay per visit
Urgent Care Facility                                                   $50 copay per visit

CALENDAR YEAR OUT-OF-POCKET MAXIMUM                                        You Pay
Individual                                                                   $1,500
Family                                                                       $3,000

LIFETIME MAXIMUM                                                          Plan Pays
Per covered individual                                                    $1,500,000




Summary of Benefits                              2
                     Type of Care                                           Benefit Level*
WELLNESS CARE                                                                    You Pay
Routine Physical Exam
(employee, spouse and children age 18 and over)                              $15 copay per visit
     1 exam every 12 months
Well-Child Visits
(includes immunizations and inoculations)
     7 exams in first 12 months of life                                      $15 copay per visit
     2 exams in months 1324
     1 exam every 12 months thereafter to age 18
Routine Annual Gyn Exam
(includes one Pap smear and related lab fees)                                $20 copay per visit
   1 exam per calendar year
Routine Mammogram
   1 mammogram per calendar year for women age 40                            $20 copay per visit
   and over
Routine Prostate Screenings
   1 prostate specific antigen and digital rectal exam                       $20 copay per visit
   per calendar year for males age 40 and over
Routine Colonoscopy
                                                                             $20 copay per visit
   beginning at age 50 for those at average risk
Routine Vision and Hearing Exams                                                Not covered
OFFICE VISITS (NON-SURGICAL)                                                     You Pay
PCP
(general practitioner, family practitioner, pediatrician or                  $15 copay per visit
internist)
Specialist                                                                   $20 copay per visit
Retail Clinic                                                                $15 copay per visit
                                                                             $20 copay per visit
Allergy Testing and Treatment
                                                              Copay waived when there is no office visit charge
Short-Term Rehabilitation
    combined maximum of 60 visits per calendar year                          $20 copay per visit
    for speech, physical and occupational therapy
Spinal Manipulation
                                                                             $20 copay per visit
    20 visits per calendar year
FAMILY PLANNING                                                                  You Pay
                                                                      Office visit  $20 copay per visit
Voluntary Sterilization                                                 Outpatient facility  no copay
                                                                   Inpatient  $150 copay per admission




                                                         3                      Summary of Benefits
                       Type of Care                                         Benefit Level*
FAMILY PLANNING (cont’d)                                                        You Pay
Infertility Services                                                 Office visit  $20 copay per visit
    $20,000 lifetime maximum for all infertility services,            Outpatient facility  no copay
    including injectable infertility drugs                        Inpatient  $150 copay per admission
                                                                 Office visit  $20 copay for the first visit
Maternity Care
                                                                  Delivery  $150 copay per admission
HOSPITAL CARE                                                                   You Pay
Hospital Care
(room and board covered up to the facility’s semi-private               $150 copay per admission
room rate)
Hospital Outpatient Care                                                         No copay
SURGERY AND ANESTHESIA                                                          You Pay
Inpatient Surgery                                            Subject to inpatient hospital copay shown above
Outpatient Surgery                                                               No copay
Anesthesia                                                                       No copay
ALTERNATIVES TO HOSPITAL CARE                                                   You Pay
Skilled Nursing Facility Care                                           $150 copay per admission
                                                                          Outpatient – no copay
Hospice Care
                                                                  Inpatient – $150 copay per admission
Home Health Care                                                                 No copay
                                                                                 No copay
Private Duty Nursing
                                                                 Must be approved in advance by Aetna
EMERGENCY CARE                                                                  You Pay
Emergency Care                                                   $50 copay per visit (waived if admitted)
Non-Emergency Care in an Emergency Room                                         Not covered
URGENT CARE                                                                     You Pay
Urgent Care Facility                                                        $50 copay per visit
Non-Urgent Care in an Urgent Care Facility                                      Not covered
AMBULANCE SERVICES                                                              You Pay
Emergency                                                         No copay when medically necessary
Non-Emergency                                                                   Not covered
BEHAVIORAL HEALTH CARE                                                          You Pay
Mental Health Treatment
                                                                        $150 copay per admission
    inpatient
    outpatient                                                              $20 copay per visit




Summary of Benefits                                    4
                    Type of Care                                            Benefit Level*
BEHAVIORAL HEALTH CARE (cont’d)                                                 You Pay
Substance Abuse Treatment
                                                                        $150 copay per admission
     inpatient
     outpatient                                                             $20 copay per visit
PRESCRIPTION DRUGS                                                              You Pay
                                                                  No copay – Bayer brand-name drugs
Retail Pharmacy                                                         $5 copay – generic drugs
     up to a 34-day supply                                      $10 copay – brand-name formulary drugs
                                                              $25 copay – brand-name non-formulary drugs
                                                                  No copay – Bayer brand-name drugs
Mail Order Pharmacy                                                     $10 copay – generic drugs
     35-90 day supply                                           $20 copay – brand-name formulary drugs
                                                              $50 copay – brand-name non-formulary drugs
OTHER COVERED EXPENSES                                                          You Pay
                                                                 Office visit – subject to office visit copay
Diagnostic X-Ray and Lab Tests
                                                                      Outpatient facility – no copay
X-Ray, Radium and Radioactive Isotope Therapy                               $20 copay per visit
Durable Medical Equipment                                                        No copay
 1
     Coverage for in-network services is based on the negotiated charge. You are not responsible for
      charges in excess of the negotiated charge.




                                                     5                          Summary of Benefits
How the Plan Works
In-Network Care
The Aetna Select Plan covers a wide range of medical services and supplies for the treatment of
illness and injury. The plan gives you and your family access to a network of primary care
physicians (PCPs), specialists, hospitals and other health care providers. These providers are
independent physicians and facilities that meet Aetna’s strict requirements for quality and service,
and are monitored for quality of care, patient satisfaction, cost-effectiveness of treatment, office
standards and ongoing training.
Doctors, hospitals and other health care providers who belong to Aetna’s network are called “in-
network” providers. You can find in-network providers by visiting www.aetna.com and logging
in to your secure member website. To find an in-network provider:
                                              ®
        Click on Find Health Care in DocFind .
        Under Provider Category, select Medical Providers, and choose the type of provider
        you’d like to find.
        Follow the prompts to define your search. When asked to select a plan, click on
                     SM
        Aetna Select .

You and your covered dependents must select a Primary Care Physician (PCP) when you enroll.
  Each covered family member may select his or her own PCP. Your PCP will provide basic
          medical care and refer you to specialists and other health care providers.

The plan covers medically necessary care you receive from your PCP or on referral by your
PCP. When your care is provided or referred by your PCP, the care is considered in-network
care, and you are responsible for the copayment shown in the Summary of Benefits.
When you receive care from your PCP or your PCP refers you to a specialist or other health care
provider in the network:
        Your in-network provider will be responsible for obtaining any necessary authorization
        from Aetna for your care.
        You do not have to submit claim forms. Your in-network provider will take care of claim
        submission.

The Primary Care Physician
Consult your PCP whenever you have questions about your health. Your PCP will provide your
primary care and, when medically necessary, your PCP will refer you to other doctors or facilities
for treatment. The referral is important because it is how your PCP arranges for you to receive
necessary, appropriate care and follow-up treatment. Except for certain direct access and
emergency services, you must have a prior written or electronic referral from your PCP to
receive coverage for all services and any necessary follow-up treatment.




How the Plan Works                                6
Referrals
Your PCP may refer you to a specialist or facility for treatment or for covered preventive care
services, when medically necessary. You must have a prior written or electronic referral from
your PCP in order to receive coverage for any services the specialist or facility provides.


 You cannot request referrals after you visit a specialist or hospital. You must contact your PCP
  and get authorization from Aetna (when applicable) before seeking specialty or hospital care.

When your PCP refers you to an in-network specialist or facility for covered services, you will be
responsible for the copayment shown in the Summary of Benefits. To avoid costly and
unnecessary bills, follow these steps:
1. Always consult your PCP first when you need medical care. Your PCP will provide the care
   you need or, if he or she considers it medically necessary, you will get a written or electronic
   referral to an in-network specialist or facility.
2. Review the referral with your PCP. Make sure you understand what specialist services are
   being recommended and why.
3. Present the referral to the specialist. The referral is necessary to have specialist services
   covered. Without the referral, you must pay the total cost of these services.
4. If you need additional services from the specialist, you must get another referral from your
   PCP. Additional treatments or tests that are covered services require another referral from
   your PCP. If it is not an emergency and you go to another doctor or facility without your
   PCP’s referral, you must pay the bill yourself.
5. Your PCP may refer you to an out-of-network provider for covered services that are not
   available within the network. Services from out-of-network providers require prior approval by
   Aetna in addition to a special out-of-network provider referral from your PCP. When
   approved, these services are covered after the applicable copayment.

Direct Access for Ob/Gyn Services
Female members covered by this plan are allowed direct access to a licensed/certified network
provider for covered ob/gyn services. There is no requirement to obtain authorization of care
from your PCP for visits to a network provider of your choice for pregnancy, well-woman
gynecological exams, primary and preventive gynecological care, routine mammograms and
acute gynecological conditions.


Out-of-Network Care
Out-of-network care is not covered, except in an emergency or with prior approval from Aetna.




                                                 7                         How the Plan Works
Sharing the Cost
Copayments (copays)
A copayment is a flat fee that you pay at the time you receive certain services:
        An office visit copay applies to most visits to a physician’s office.
        A copay applies to inpatient hospital, skilled nursing facility, hospice and behavioral
        health treatment facility care.
        A copay applies when you use a hospital emergency room or urgent care facility.
        Copays apply when you purchase prescription drugs.
Refer to the Summary of Benefits for information about the copayments that apply to specific
services.

Out-of-Pocket Maximum
The annual out-of-pocket maximum is the most you pay for copayments (excluding prescription
drug copayments) in a calendar year. Once a person meets the annual out-of-pocket maximum,
the plan pays 100% of charges for that person’s covered medical expenses for the rest of the
calendar year. When your family’s combined copayment expenses satisfy the family out-of-
pocket maximum shown in the Summary of Benefits, the plan pays 100% of the family’s covered
medical charges for the remainder to the calendar year.
The following expenses do not apply toward the out-of-pocket maximum:
        Prescription drug copayments.
        Charges for services and supplies that are not covered by the plan.
Each January 1, you start over with a new out-of-pocket maximum.


After you meet the out-of-pocket maximum, you must still pay the applicable copay each time you
                                  purchase prescription drugs.


Lifetime Maximum
The lifetime maximum is the most the plan will pay in benefits for a covered person in his or her
lifetime. This lifetime maximum is $1,500,000.




How the Plan Works                                 8
What the Plan Covers
Wellness Care
Routine Physical Exams
The plan covers routine physical exams given to you, your spouse or your dependent child.
In addition to the office visit, the plan covers:
        X-rays, lab and other tests given in connection with the exam; and
        Materials for giving immunizations for infectious disease and testing for tuberculosis.

                   Refer to the Summary of Benefits for age and frequency rules.

The physical exam must include at least:
        A review and written record of the patient’s complete medical history;
        A check of all body systems; and
        A review and discussion of exam results with the patient or with a parent or guardian.

Routine Gyn Exams
The plan covers one routine gyn exam per calendar year, including one Pap smear and related
lab fees.

Routine Cancer Screenings
The plan covers:
        One mammogram per calendar year for women age 40 and over;
        One digital rectal exam (DRE) and prostate specific antigen (PSA) test each calendar
        year for men age 40 and over;
        One annual fecal occult blood stool test for you and covered family members age 40 and
        over; and
        Routine colonoscopies, beginning at age 50.




                                                 9                       What the Plan Covers
 Outpatient Care
Office Visits
The plan covers treatment of an illness or injury in a physician’s office.

Retail Clinics
A retail clinic is a free-standing health care facility. Aetna has contracts with certain retail clinics
to improve access to routine health care. The plan covers visits to these participating retail clinics
for non-emergency treatment of an illness or injury, and for administration of certain
immunizations.
To find a participating clinic in your area, use the DocFind online directory at www.aetna.com.
Under Provider Category, select Facilities, then choose Walk-In Clinics as the Provider Type.


               Retail clinics are not an alternative to emergency room services, and
                             they do not provide ongoing physician care.


Short-Term Rehabilitation
The plan covers charges for short-term rehabilitation made by a hospital, licensed health care
facility, physician, or licensed or certified physical, occupational or speech therapist. The
services must be provided according to a specific treatment plan that details the treatment to be
provided (including how long and how often).
Short-term rehabilitation is therapy expected to improve a body function (including speech) lost or
impaired because of an injury, disease or congenital defect. The plan covers physical,
occupational and speech therapy given on an outpatient basis and expected to improve the
person’s condition within 60 days after therapy starts. Benefits are paid for up to 60 visits per
calendar year.

Spinal Manipulation
The plan covers charges for spinal manipulation to treat any condition caused by or related to
biomechanical or nerve conduction disorders of the spine. The plan pays benefits for up to 20
visits per calendar year.

Hospital Outpatient Care
The plan covers charges made by a hospital for covered services and supplies provided to a
person receiving outpatient treatment. “Outpatient” means the person is not confined overnight in
the hospital.




What the Plan Covers                              10
Outpatient Surgery
The plan covers charges made by a surgery center, hospital outpatient department or physician
for outpatient surgery services and supplies when the surgery is performed in the surgery center
or a hospital. The procedure must meet these tests:
        It is not expected to result in extensive blood loss, require major or prolonged invasion of
        a body cavity or involve any major blood vessels;
        It can be safely and adequately performed only in a surgery center or hospital; and
        It is not normally performed in the office of a physician or dentist.
The plan does not cover (as part of outpatient surgery) services of a physician who provides
technical assistance to the operating physician.


Family Planning
Voluntary Sterilization
The plan covers charges for a vasectomy or tubal ligation made by a physician or hospital.
The plan does not cover charges for the reversal of a sterilization procedure.

Contraceptives
The plan covers IUDs and the associated office visit as a medical expense.
Refer to Prescription Drugs for information about coverage for oral contraceptives and
contraceptive devices.

Infertility Services
The plan covers an initial evaluation, including a history, physical exam and laboratory studies
performed at an appropriate participating laboratory.
If your physician diagnoses you as infertile, and the diagnosis is documented in your medical
records, the plan covers charges made by a hospital or physician for comprehensive infertility
services performed on an outpatient basis.
The plan’s coverage of comprehensive infertility services includes:
        Evaluation of ovulatory function;
        Ultrasound of ovaries at an appropriate participating radiology facility;
        Postcoital test;
        Hysterosalpingogram;
        Endometrial biopsy;
        Hysteroscopy;
        Ovulation induction with ovulatory stimulant drugs; and
        Intrauterine insemination.




                                                  11                       What the Plan Covers
If the comprehensive infertility services do not result in a pregnancy, the plan covers the following
advance reproductive technology (ART) services when performed on an outpatient basis and
approved in advance by Aetna’s Infertility Case Management Unit:
        In vitro fertilization (IVF);
        Zygote intrafallopian transfer (ZIFT);
        Gamete intrafallopian transfer (GIFT);
        Cryopreserved embryo transfers;
        Intracytoplasmic sperm injection (ICSI) or ovum microsurgery;
        Care of a person covered by the plan who is participating in a donor IVF program,
        including fertilization and culture; and
        Services to obtain a partner’s sperm if both the man and woman are covered by the plan.


The lifetime maximum benefit for comprehensive infertility services and advanced reproductive
technology is $20,000.


 Call Aetna Member Services before you receive ART services. Member Services will refer your
                      call to Aetna’s Infertility Case Management Unit.



The plan does not cover (as part of infertility services or ART):
        Infertility services for couples in which one of the partners has had a previous sterilization
        procedure, with or without surgical reversal;
        Reversal of a sterilization procedure;
        Infertility services for covered females with FSH levels 19 or greater miU/ml on day 3 of
        the menstrual cycle;
        The purchase of donor sperm and any charges for the storage of sperm;
        The purchase of donor eggs;
        The care of the donor required for donor egg retrievals or transfers;
        Cryopreservation and the storage, transfer or thawing of cryopreserved eggs and
        embryos, including any associated services;
        The services of a gestational carrier or surrogate, including programs for gestational
        carriers or surrogate parenting for the member or gestational carrier;
        Home ovulation prediction kits;
        Services received by a spouse or partner who is not covered by the plan;
        Infertility services that are not reasonably likely to succeed; or
        Prescription drugs, except injectable infertility medications.
        Oral fertility medications may be covered by the Prescription Drug Program – refer to
        Covered Drugs in the Prescription Drugs section of this book.




What the Plan Covers                              12
Maternity Care
The plan covers the inpatient care of a covered mother and newborn child for a minimum of:
        48 hours after a vaginal delivery; and
        96 hours after a cesarean section.


Inpatient Care
Hospital Care
The plan covers charges made by a hospital for providing room and board and hospital services
when you are confined as an inpatient. These charges are covered up to the facility’s semi-
private room rate.

Skilled Nursing Facility Care
The plan covers charges made by a skilled nursing facility if you are confined as an inpatient
and recovering from a disease or injury.


Transplant Services

                       Transplant services must be preauthorized by Aetna.
     Call Member Services at 1-800-560-3724 when you and your physician begin to discuss
transplant services. Member Services can answer benefit questions, help you find an in-network
  provider, tell you about the services offered by the National Medical Excellence Program, and
refer you to the Special Case Customer Service Unit to start the transplant authorization process.

The plan covers:
        Evaluation;
        Compatibility testing of prospective organ donors who are family members;
        Charges for activating the donor search process with national registries;
        The direct costs of obtaining the organ. Direct costs include surgery to remove the organ,
        organ preservation and transportation, and hospitalization of a live donor provided that
        the expenses are not covered by the donor’s group or individual health plan;
        Physician or transplant team services for transplant expenses;
        Hospital inpatient and outpatient supplies and services, including:
           Physical, speech and occupational therapy;
           Biomedicals and immunosuppressants;
           Home health care services; and
           Home infusion services.
        Follow-up care.




                                                 13                      What the Plan Covers
As part of the transplant benefit, the plan does not cover:
        Services and supplies provided to a donor when the recipient is not covered by this plan;
        Outpatient drugs, including biomedicals and immunosuppressants, except as provided
        above;
        Home infusion therapy after the transplant;
        Harvesting or storage of organs without the expectation of an immediate transplant for an
        existing illness; or
        Harvesting or storage of bone marrow, tissue or stem cells without the expectation of a
        transplant to treat an existing illness within 12 months.
Aetna offers a wide range of support services to those who need a transplant or other complex
medical care. If you need a transplant, you or your physician should contact Aetna’s National
                             ®
Medical Excellence Program at 1-877-212-8811. A nurse case manager will provide the support
you and your physician need to make informed decisions about your care.

The Institutes of Excellence™ Network
Through the Institutes of Excellence™ (IOE) network, you have access to a provider network that
specializes in transplants. Each facility in the IOE network has been selected to perform only
certain types of transplants, based on quality of care and successful clinical outcomes.
Through the IOE program, you can receive care for the following transplants:
        Bone marrow                                           Kidney and pancreas
        Heart                                                 Liver
        Heart and lung                                        Lung
        Intestinal (small bowel)                              Pancreas
        Kidney
The plan will cover the transplant as in-network care if it is performed at an IOE facility.
Transplants listed above that are performed at any non-IOE facility are considered out-of-network
care, even if the facility is considered a network facility for other types of care. The plan does not
cover transplants performed at a non-IOE facility.




What the Plan Covers                             14
Hospice Care
The plan covers hospice care provided as part of a hospice care program to a patient who is
terminally ill, including:
        Inpatient charges made by a hospice facility, hospital or skilled nursing facility for
        room and board and other services and supplies provided for pain control and other
        acute and chronic symptom management, up to the facility’s semi-private room rate;
        Services and supplies provided on an outpatient basis;
        Charges made by a hospice care agency; including
           Part-time or intermittent nursing care by an RN or LPN for up to 8 hours in any one
            day;
           Part-time or intermittent home health aide services for up to 8 hours in any one day.
            These services consist mainly of caring for the person;
           Medical social services under a physician’s direction;
           Physical and occupational therapy; and
           Medical supplies; and
        Home health care agency expenses, including:
           Physical and occupational therapy;
           Part-time or intermittent home health aid services for up to 8 hours in any one day.
            These consist mainly of caring for the person; and
           Psychological and dietary counseling.
The plan does not cover (as part of hospice care):
        Bereavement counseling;
        Funeral arrangements;
        Pastoral counseling;
        Financial or legal counseling, including estate planning and the drafting of a will;
        Homemaker or caretaker services; or
        Respite care.


Home Health Care
The plan covers home health care expenses when care is provided by a home health care
agency as part of a home health care plan and the care is provided in your home.
Each 4-hour visit by a nurse or therapist is considered one visit; each 4 hours of home health aide
services is considered one visit.




                                                 15                       What the Plan Covers
Emergency Care
You are covered 24 hours a day, 7 days a week, anywhere in the world, if care is needed to treat
an emergency medical condition.
The plan covers hospital services provided in an emergency room to evaluate and treat an
emergency medical condition.


         The plan does not cover non-emergency care provided in an emergency room.



Ambulance
The plan covers charges made for a professional ambulance for:
        Transportation in a medical emergency to the first hospital where treatment is given;
        Transportation in a medical emergency from one hospital to another hospital when the
        first hospital does not have the required services or facilities for your condition; and
        Transportation from the hospital to home or to another facility when an ambulance is
        medically necessary for safe and adequate transport.
The plan also covers air ambulance services for:
        Emergency transportation from your home or from the location of an accident, illness or
        injury to a facility where treatment can be given; and
        Transportation in a medical emergency from one hospital to another hospital when the
        first hospital does not have the required services or facilities for your condition.


Mental Health and Substance Abuse Care

  You are encouraged to call Aetna Behavioral Health at 1-800-424-4047 before admission to a
                   hospital or treatment facility for behavioral health care.

The plan includes coverage for behavioral health care. To be covered by the plan, the care must
be for:

        The effective treatment of alcoholism or drug abuse; or
        The effective treatment of a mental disorder.

Mental Health Treatment
The plan covers the following services for mental health treatment:
        Inpatient medical, nursing, counseling and therapeutic services in a hospital or non-
        hospital residential facility, appropriately licensed by the Department of Health or its
        equivalent.
        Short-term evaluation and crisis intervention mental health services provided on an
        outpatient basis.




What the Plan Covers                             16
Treatment of Alcohol and Drug Abuse
The plan covers the following services for the treatment of alcohol and drug abuse:
        Inpatient care for detoxification, including medical treatment and referral services for
        substance abuse or addiction.
        Inpatient medical, nursing, counseling and therapeutic rehabilitation services for the
        treatment of alcohol or drug abuse or dependency in a hospital or treatment facility,
        appropriately licensed by the Department of Health or its equivalent.
        Outpatient visits for substance abuse detoxification, including diagnosis and medical
        treatment.
        Outpatient visits to a behavioral health provider for diagnostic, medical or therapeutic
        rehabilitation services for substance abuse.


Oral Surgery
The plan covers the following types of oral surgery:
The plan covers treatment of accidental injury to natural teeth and oral surgery that is considered
medical- or dental-in-nature, including
        Services of a physician or dentist for treatment of the following conditions of the teeth,
        mouth, jaws, jaw joints, or supporting tissues if medically necessary:
           Surgery necessary to treat a fracture, dislocation or wound;
           Surgery to cut out:
             teeth partly or completely impacted in the bone of the jaw;
             teeth that will not erupt through the gum;
             other teeth that cannot be removed without cutting into bone;
             the roots of a tooth without removing the entire tooth; or
             cysts, tumors or other diseased tissue.
           Surgery to cut into the gums and tissues of the mouth. This is only covered when not
            done in connection with the removal, replacement, or repair of teeth.
           Surgery necessary to alter the jaw, jaw joints or bite relationships by a cutting
            procedure when appliance therapy alone cannot result in functional improvement;
           Non-surgical treatment of infections or diseases not related to the teeth.
        Treatment of accidental injury to sound natural teeth or tissues of the mouth. The
        treatment must occur within one year of the accident.
        At the time of the accident, the teeth must have been free from decay (or in good repair)
        and firmly attached to the jaw bone.
        The plan’s coverage of dentures, bridgework, crowns, and appliances is limited to:
           The first denture or fixed bridgework to replace lost teeth;
           The first crown (cap) needed to repair each damaged tooth; and
           An in-mouth appliance used in the first course of orthodontic treatment after the
            injury.




                                                 17                        What the Plan Covers
Except as described above to treat accidental injury, the plan does not cover charges:
        For in-mouth appliances, crowns, bridgework, dentures, tooth restorations, or any related
        fitting or adjustment services, whether or not the purpose of these services or supplies is
        to relieve pain;
        For root canal therapy;
        For routine tooth removal;
        To remove, repair, replace, restore or reposition teeth lost or damaged in the course of
        biting or chewing;
        To repair, replace or restore fillings, crowns, dentures or bridgework;
        For non-surgical periodontal treatment;
        For dental cleaning, in-mouth scaling, planing or scraping; or
        For myofunctional therapy. This is muscle training therapy or training to correct or control
        harmful habits.


Temporomandibular Joint Dysfunction (TMJ) Disorder
The plan covers medical-in-nature treatment of TMJ disorder, including exams, X-rays, injections,
anesthetics, physical therapy and oral surgery. The plan does not cover appliances used to treat
TMJ disorder, or procedures and/or restoration services that would have been necessary in the
absence of the TMJ disorder.


    If you and your physician are considering surgery for a TMJ disorder, you are encouraged to
 contact Member Services before the surgery is performed. Claims for surgical treatment of TMJ
  disorder must be approved by an Aetna Medical Director. The Medical Director will review your
 proposed treatment, and Aetna will let you know what benefits will be paid by the plan based on
the information provided. You and your physician can then decide how to proceed. The advance
   review process is not a guarantee of benefit payment, but rather an estimate of the amount or
         scope of benefits to be paid to help you make an informed decision about your care.




What the Plan Covers                              18
Other Covered Expenses
The plan also covers charges for:
        Diagnostic lab work and X-rays;
        X-ray, radium and radioactive isotope therapy;
        Anesthetics and oxygen;
        The rental of durable medical equipment (such as crutches and wheelchairs) or:
           The purchase of such equipment if the patient needs long-term care and if the
            equipment either can’t be rented or is likely to cost less to buy than to rent.
           Repair of purchased equipment.
           Replacement of purchased equipment if Aetna is shown that it is needed because of
            a change in the patient’s condition, or if it’s likely to cost less to buy a replacement
            than to repair existing equipment or rent the same kind of equipment.

        Internal and external prosthetic devices and special appliances, if the device or appliance
        improves or restores body part function that has been removed or damaged due to illness
        or injury. The plan covers the first prosthesis you need, and replacement costs if:
         The replacement is needed because of a change in your physical condition; or
           It is likely to cost less to buy a new one than to repair the existing one; or
           The existing one cannot be made serviceable.




                                                  19                       What the Plan Covers
Prescription Drugs
The plan covers prescription drugs that are prescribed to treat an illness or injury. The
prescription drugs must be:
        Necessary for the care and treatment of an illness;
        Prescribed in writing by a physician; and
        Not listed under What the Prescription Drug Plan Does Not Cover, below.

Drugs that you need while you are confined in a hospital or other covered health care facility may
  be covered as part of your inpatient benefit – refer to the sections of this book that describe
                            inpatient benefits for more information.

You have two ways to fill prescriptions: at a retail pharmacy or by mail order, through Aetna Rx
Home Delivery. The amount you pay for your prescription depends on what type of drug is used
(generic drug or brand-name drug; formulary or non-formulary), as explained below.


Formulary Drugs
Coverage is based upon Aetna’s formulary. The formulary is a list of preferred drugs that
includes both brand name and generic drugs. You can reduce your copayment by using a
covered generic drug or a covered brand-name drug that appears on the formulary. Your
copayment will be highest if your physician prescribes a covered brand-name drug that does not
appear on the formulary.
You can find Aetna’s formulary online at www.aetnapharmacy.com, or call Member Services at
the number on your ID card to request a printed formulary guide without charge.


Retail Pharmacy
You may purchase up to a 34-day supply of a covered prescription drug at your local retail
pharmacy, with refills as authorized by your physician.
The pharmacy must be a participating pharmacy that belongs to Aetna’s pharmacy network.
When you use in-network pharmacies, there are no claim forms to complete. Simply show your
ID card and pay your copay at the time of your purchase.
You can find a list of in-network pharmacies online at www.aetna.com. Log in to your secure
member website, then click on Find Health Care in DocFind).


             The plan does not cover prescription drugs you purchase at a pharmacy
                                that is not in the Aetna network.




Prescription Drugs                               20
Mail Order
Aetna Rx Home Delivery is a convenient way to purchase medications that you take regularly for
the treatment of a chronic health condition, such as hypertension or diabetes. The mail order
program allows you to purchase a 35 to 90-day supply, and delivers the medicine to your
doorstep.

New Prescriptions
To use the mail order service, you generally need to ask your doctor to write two prescriptions –
one for a 90-day supply that you can fill through the mail order program, plus a 34-day
prescription to purchase an immediate supply at your local retail pharmacy.
You must fill out an order form for each new prescription. You can download an order form at
www.aetnarxhomedelivery.com. Or you can call Member Services to request a form.

Refills
Each time you order medications by mail, you will receive a prescription receipt that includes a
refill date indicating when your prescription can be refilled, as authorized by your physician. You
can request a refill after that date. Allow at least 14 days for processing your order. To order a
refill:
        Log in to www.aetnarxpharmacy.com and complete all of the information requested.
        You can also track prescription orders through this website; or
        Call Aetna Rx Home Delivery toll-free at 1-866-612-3862 (TDD 1-800-201-9457). Provide
        your health plan member ID number, your prescription number and your credit card
        number; or
        Fill out the Prescription Drug Order Form you received with your medications and mail
        your refill request to Aetna Rx Home Delivery.


Precertification
Your physician must request prior authorization by Aetna for certain prescription drugs before
your prescription can be filled. This process is called precertification. Precertification helps
encourage the appropriate and cost-effective use of prescription drugs.
The precertification program is based upon current medical findings, manufacturer labeling, FDA
guidelines, and cost information. For these purposes, cost information includes any manufacturer
rebate arrangements between Aetna and the manufacturers of certain drugs on Aetna’s
formulary.


The drugs requiring precertification are subject to change. Call Member Services or visit Aetna’s
                          website for the current Precertification List.




                                                 21                          Prescription Drugs
Therapeutic Class Management
Therapeutic Class Management (TCM) is a focused precertification process for three types of
therapeutic prescription drugs. TCM promotes patient safety by putting limits on the quantity of
these drugs that can be dispensed.
Your physician must get prior authorization before drugs in the following classes can be
dispensed:


Antifungals                   Non-sedating antihistamines          Proton pump inhibitors

    Diflucan (QL)                 Allegra                               Protonix
    Lamisil                       Allegra-D                             Nexium
    Penlac Nail Lacquer           Clarinex                              Prilosec
    Sporanox                      Semprex-D                             Omeprazole
    Vfend                         Zyrtec
                                  Zyrtec-D


If your physician prescribes a drug in one of these classes, he or she must call Aetna to precertify
the prescription. Aetna will review the request and make a decision within 24 hours.


 The drugs requiring TCM are subject to change. Call Member Services for the current TCM list.



Step Therapy Program
The prescription drug program includes a step-therapy requirement. Step-therapy is a type of
precertification. Certain drugs are not covered unless you have tried one or more “prerequisite
therapy” medication(s) first. There may be times, however, when it is medically necessary for you
to use a step-therapy medication as initial therapy without first trying a prerequisite therapy drug.
In that situation, your doctor can request coverage of the step-therapy medication as a medical
exception by contacting the Pharmacy Management Precertification Unit.
The step-therapy program is based upon current medical findings, manufacturer labeling, FDA
guidelines and cost information. For these purposes, “cost information” includes any
manufacturer rebate arrangements between Aetna and the manufacturers of certain drugs on
Aetna’s Formulary.




Prescription Drugs                               22
Specialty Pharmacy
Patients with chronic medical conditions often need medications that are not readily available at a
local pharmacy. These medications may require special storage and handling, and sometimes
they have side effects that must be carefully monitored.
Aetna Specialty Pharmacy provides specialty medications and clinical support for patients with
chronic medical conditions such as:
        Asthma                                            Infertility
        Blood disorders                                   Multiple Sclerosis
        Cancer                                            Osteoporosis
        Chronic renal failure                             Psoriasis
        Cystic fibrosis                                   Pulmonary disease
        Growth hormone deficiency                         Rheumatoid arthritis
        Hepatitis                                         Transplants
        HIV/AIDS
Aetna Specialty Pharmacy will work with you and your physician to ensure that you are on the
right medication therapy, have the medications and supplies you need, and know how to
administer your medications.
Ordering your medications from Aetna Specialty Pharmacy is easy:
        Your physician can fax the prescription.
        You or your physician can mail the prescription to:
        Aetna Specialty Pharmacy
        503 Sunport Lane
        Orlando, FL 32809
        Your physician can call Aetna Specialty Pharmacy at 1-866-782-2779.
Your medications will usually be shipped within 2448 hours. A welcome packet in your first
delivery will tell you about the services offered by Aetna Specialty Pharmacy, explain how to
order refills, and provide important contact information.



  You can reach Aetna Specialty Pharmacy 24-hours-a-day, 7 days a week at 1-866-782-2779.




                                                   23                       Prescription Drugs
Covered Drugs
The plan covers:
        Federal legend drugs – drugs that require a label stating: “Caution: Federal law prohibits
        dispensing without prescription”;
        Compounded medication, of which at least one ingredient is a federal legend drug;
        Any other drug which under the applicable state law may be dispensed only upon the
        written prescription of a physician;
        Insulin;
        Insulin needles and syringes;
        Over the counter diabetic supplies;
        Oral contraceptives and contraceptive devices, including the patch and ring;
        Oral fertility drugs; and
        Drugs to treat erectile dysfunction, up to 24 tablets per 90-day period.


What the Prescription Drug Plan Does Not Cover
The prescription drug plan does not cover the following prescription drug expenses:

        Any drug that does not, by federal or state law, require a prescription, such as an over-
        the-counter drug or equivalent over-the-counter product, even when a prescription is
        written for it.
        More than a 34-day supply of a prescription filled at a retail pharmacy.
        Less than a 35-day supply, or more than a 90-day supply, of any prescription filled
        through Aetna Rx Home Delivery, the plan’s mail order service.
        Any prescription drug dispensed by a mail order pharmacy other than Aetna Rx Home
        Delivery.
        More than the number of refills specified by the prescribing doctor. Aetna may require a
        new prescription or proof of need if the prescriber has not specified the number of refills
        or if the frequency or number of refills seems excessive under accepted medical practice
        standards.
        Any refill of a drug dispensed more than one year after the latest prescription for it, or as
        permitted by law where the drug is dispensed.
        Any drug entirely consumed when and where it is prescribed.*

        Any drug provided by a health care facility or while you are an inpatient there. Also, any
        drug provided on an outpatient basis by a health care facility if benefits are paid for it
        under any other part of this plan or another plan sponsored by your employer.
        Administration or injection of any drug.*
        A device of any type (such as a spacer or nebulizer) used in connection with a
        prescription drug. Note that some devices may be covered as durable medical
        equipment or as part of another benefit.




Prescription Drugs                               24
Appetite suppressants.
Biological sera and blood products.*
Contraceptives, except oral contraceptives and devices. The prescription drug plan does
not cover implants or injectables for contraception.
Injectable fertility medications.
Immunization agents.*
Nutritional supplements (unless they are the only source of nutrition in a life-sustaining
situation).
Smoking cessation aids or drugs.
Vitamins.
More than 24 tablets of an erectile dysfunction medication per 90-day period.
Any drug dispensed by a mail order pharmacy to be used to treat erectile dysfunction,
impotence, or sexual dysfunction or inadequacy.


*These expenses may be covered under the medical portion of your plan.




                                         25                          Prescription Drugs
What the Plan Does Not Cover
The plan does not cover:
       Acupuncture and acupuncture therapy, except when performed by a network physician
       as a form of anesthesia in connection with a covered surgery.
       Ambulance services, when used as routine transportation to receive inpatient or
       outpatient services.
       Any service in connection with, or required by, a procedure or benefit not covered by the
       plan.
       Biofeedback, except as specifically approved by Aetna.
       Blood, blood plasma, or other blood derivatives or substitutes.
       Breast augmentation or reduction.
       Canceled office visits or missed appointments.
       Care for conditions that, by state or local law, must be treated in a public facility, including
       mental illness commitments.
       Care furnished to provide a safe surrounding, including the charges for providing a
       surrounding free from exposure that can worsen the disease or injury.
       Charges for a service or supply furnished by an in-network provider that exceed the
       provider’s negotiated charge for that service or supply. This exclusion will not apply to
       any service or supply for which a benefit is provided under Medicare before the benefits
       of the plan are paid.
       Charges for services and supplies:
          Furnished, paid for, or for which benefits are provided or required by reason of the
           past or present service of any person in the armed forces of a government.
          Furnished, paid for, or for which benefits are provided or required under any law of a
           government. This exclusion will not apply to “no-fault” auto insurance if it: (a) is
           required by law; (b) is provided on other than a group basis; and (c) is included in the
           definition of “other group plans” in the plan’s coordination of benefits provision. In
           addition, this exclusion will not apply to: (a) a plan established by a government for its
           own employees or their dependents; or (b) Medicaid.
       Charges that you are not legally obliged to pay.
       Contraceptives, except as described in Family Planning and Prescription Drugs.
       Cosmetic surgery or surgical procedures primarily for the purpose of changing the
       appearance of any part of the body to improve or alter appearance or self-esteem,
       whether or not for psychological or emotional reasons. However, the plan covers the
       following:
          Reconstructive surgery to correct the results of an injury.
          Surgery to improve the function of a part of the body that is not a tooth or structure
           that supports the teeth and is malformed as the result of:
            A congenital defect (such as a cleft lip and cleft palate), or
            A disease, or
            Surgery performed to treat a disease or injury.


Exclusions                                       26
   Surgery to reconstruct a breast after a mastectomy that was done to treat a disease
    or as a continuation of a staged reconstructive procedure.
Court-ordered services and services required by court order as a condition of parole or
probation.
Custodial care and rest cures.
Dental care and treatment, except as described in What the Plan Covers.
Educational services, special education, remedial education or job training. The plan
does not cover:
   Evaluation or treatment of learning disabilities, minimal brain dysfunction,
    developmental and learning disorders, behavioral training or cognitive rehabilitation.
   Services, treatment, and educational testing and training related to behavioral
    (conduct) problems, learning disabilities and developmental delays.
Expenses that are the legal responsibility of Medicare or a third-party payer.
Eyeglasses, vision aids, hearing aids and communication aids.
False teeth.
Hair analysis.
Health services, including those related to pregnancy, that were provided before your
coverage became effective or after your coverage was terminated.
Household equipment, including (but not limited to) the purchase or rental of exercise
cycles, air purifiers, central or unit air conditioners, water purifiers, hypoallergenic pillows,
mattresses or waterbeds..
Hypnotherapy, except when approved in advance by Aetna.
Immunizations related to travel or work.
Improvements to your home or place of work, including (but not limited to) ramps,
elevators, handrails, stair glides and swimming pools.
Infertility services, except as described in What the Plan Covers.
Marriage, family, child, career, social adjustment, pastoral or financial counseling.
The Company’s Employee Assistance Program (EAP) offers counseling services. Refer
to the description of the EAP on HR//direct online for more information.
Orthopedic shoes, foot orthotics or other devices to support the feet, unless necessary to
prevent the complications of diabetes.
Outpatient supplies, including (but not limited to) outpatient medical consumable or
disposable supplies such as syringes, incontinence pads, elastic stockings and reagent
strips.
Personal comfort or convenience items, including services and supplies that are not
directly related to medical care, such as guest meals and accommodations, barber
services, telephone charges, radio and television rentals, homemaker services, travel
expenses, take-home supplies, and other similar items and services.
Radial keratotomy, including related procedures designed to surgically correct refractive
errors.
Recreational and educational therapy, including any related diagnostic testing.
Reversal of voluntary sterilizations, including related follow-up care.



                                           27                                      Exclusions
      Routine vision and hearing exams.
      Services and supplies not medically necessary, as determined by Aetna, for the
      diagnosis, care or treatment of the disease or injury involved. This applies even if they
      are prescribed, recommended, or approved by your attending physician or dentist.
      Services of a resident physician or intern rendered in that capacity.
      Services or supplies covered by any automobile insurance policy, up to the policy’s
      amount of coverage limitation.
      Services or supplies that are associated with injuries, illnesses or conditions suffered due
      to the acts or omissions of a third party, as determined by Aetna or its authorized
      representative. See Subrogation/Reimbursement for more information about what
      happens when you have a claim for an injury or illness that was caused by a third party.
      Services or supplies that are considered to be experimental or investigational.
      Services provided by your close relative (your spouse, child, brother, sister, or the parent
      of you or your spouse) for which, in the absence of coverage, no charge would be made.
      Services required by a third party, including (but not limited to) physical examinations,
      diagnostic services and immunizations in connection with:
         Obtaining or continuing employment;
         Obtaining or maintaining any license issued by a municipal, state or federal
          government;
         Securing insurance coverage;
         Travel; and
         School admissions or attendance, including examinations required to participate in
          athletics,
      . . . unless the service is considered to be part of an appropriate program of wellness
      services.
      Special medical reports, including those not directly related to medical treatment (such as
      employment or insurance physicals) and reports prepared in connection with litigation.
      Specific non-standard allergy services and supplies, including (but not limited to):
         Skin titration (wrinkle method),
         Cytotoxicity testing (Bryan’s test),
         Treatment of non-specific Candida sensitivity, and
         Urine autoinjections.
      Speech therapy for the treatment of delays in speech development, unless resulting from
      disease, injury or congenital defects.
      Surgical operations, procedures or treatment of obesity.
      Therapy or rehabilitation, including (but not limited to):
         Primal therapy;
         Chelation therapy;
         Rolfing;
         Psychodrama;
         Megavitamin therapy;



Exclusions                                       28
   Purging;
   Bioenergetic therapy;
   Vision perception training; and
   Carbon dioxide therapy.
Thermograms and thermography.
Transsexual surgery, sex change or transformation. The plan does not cover any
procedure, treatment or related service designed to alter physical characteristics from
their biologically determined sex to those of another sex, regardless of any diagnosis of
gender role or psychosexual orientation problems.
Treatment in a federal, state or government facility, except to the extent required by
applicable laws.
Treatment, including therapy, supplies and counseling, for sexual dysfunctions or
inadequacies that do not have a physiological or organic basis.
Treatment of covered health care providers who specialize in the mental health care field
and who receive treatment as a part of their training in that field.
Treatment of diseases, injuries or disabilities related to military service for which you are
entitled to receive treatment at government facilities that are reasonably available to you.
Treatment of injuries sustained while committing a felony.
Treatment of occupational injuries and occupational diseases, including injuries that arise
out of (or in the course of ) any work for pay or profit, or in any way result from a disease
or injury that does. If you are covered under a workers' compensation law or similar law
and submit proof that you are not covered for a particular disease or injury under such
law, that disease or injury will be considered non-occupational, regardless of cause.
Weight loss services and supplies. Regardless of the existence of comorbid conditions,
the plan does not cover any treatment, drug, service or supply intended to:
   Increase or decrease body weight;
   Control weight; or
   Treat obesity (including morbid obesity).
The plan does not cover:
   Liposuction, banding, gastric stapling, gastric bypass or other forms of bariatric
    surgery;
   Surgical procedures, medical treatments, weight control or weight loss programs, and
    other services and supplies that are primarily intended to treat, or are related to the
    treatment of, obesity, including morbid obesity;
   Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and
    supplements, food or food supplements, appetite suppressants or other medications;
   Counseling, coaching, training, hypnosis or other forms of therapy; or
   Exercise programs, exercise equipment, memberships in health or fitness clubs,
    recreational therapy, or other forms of activity or activity enhancement.




                                         29                                     Exclusions
Claims
Keeping Records of Expenses
It’s important to keep records of medical expenses for each person covered by the plan. These
will be required when you file a claim for benefits. Be sure that your records include the following
for each expense:
        Names and addresses of physicians;
        The date you incur an expense; and
        Copies of all bills and receipts.


Filing Claims
You do not need to submit a claim for in-network health care expenses – your in-network
provider will take care of that for you. However, if you receive covered emergency care from an
out-of-network provider, the bill must be submitted promptly to Aetna for payment.
To file a claim, you complete a claim form. Claim forms are available from your Human
Resources representative or online (go to Aetna’s website, www.aetna.com, log in to your
secure member website, then click on Requests and Changes/Forms). The form contains
instructions on how and when to file a claim. Send your completed form to the address shown on
your ID card.
All claims must be filed promptly. The deadline for filing a claim is 90 days after the date you
incur a covered expense. If, through no fault of your own, you are unable to meet this deadline,
your claim will still be accepted if you file as soon as possible. However, if a claim is filed more
than two years after the deadline, it will not be covered unless you are legally incapacitated.
You can file claims for benefits and appeal adverse claim decisions yourself or through an
authorized representative. An “authorized representative” is a person you authorize, in writing, to
act on your behalf. The plan will also recognize a court order giving a person authority to submit
claims on your behalf, except that in the case of a claim involving urgent care, a health care
professional with knowledge of your condition may always act as your authorized representative.


Physical Exams
Aetna has the right to require an exam of any person for whom certification or benefits have been
requested. The exam will be performed at any reasonable time while certification or a claim for
benefits is pending or under review. This exam may be performed by a physician or dentist
Aetna has chosen and will be done at Aetna’s expense.


Legal Action
No legal action can be brought to recover a benefit after three years from the deadline for filing
claims.




Claims                                           30
Claim Processing
A claim occurs whenever you request:
         An authorization or referral from an in-network provider or Aetna; or
         Payment for items or services received.
Aetna will make a decision on your claim. For concurrent care claims, Aetna will send you written
notification of an affirmative benefit determination. For other types of claims, you may receive
written notice only if Aetna makes an adverse benefit determination.
Adverse benefit determinations are decisions Aetna makes that result in the denial, reduction, or
termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit
or service. Adverse benefit determinations can be made for one or more of the following reasons:
         You are not eligible to participate in the plan; or
         Aetna determines that a benefit or service is not covered by the plan because:
            It is not included in the list of covered benefits,
            It is specifically excluded,
            A plan limitation has been reached, or
            It is not medically necessary.
Aetna will provide you with written notices of adverse benefit determinations within the time
frames shown in the following chart. These time frames may be extended under certain limited
circumstances. The notice you receive from Aetna will provide important information that will
assist you in making an appeal of the adverse benefit determination, if you wish to do so.
Please see Appeals for more information about appeals.


                 Type of Claim                                         Response Time
Urgent care claim: a claim for medical care or            As soon as possible, but not later than 72 hours
treatment where delay could:
    seriously jeopardize your life or health, or your
    ability to regain maximum function; or
    subject you to severe pain that cannot be
    adequately managed without the requested
    care or treatment.
Pre-service claim: a claim for a benefit that requires                   15 calendar days
Aetna’s approval of the benefit in advance of
obtaining medical care (precertification).
Concurrent care claim extension: a request to               Urgent care claim  as soon as possible, but
extend a previously approved course of treatment.           not later than 24 hours, provided the request
                                                            was received at least 24 hours prior to the
                                                            expiration of the approved treatment.
                                                            Other claims  15 calendar days




                                                     31                                            Claims
           Type of Claim (cont’d)                                      Response Time
Concurrent care claim reduction or termination:              With enough advance notice to allow you to
a decision to reduce or terminate a course of                                appeal.
treatment that was previously approved.
Post-service claim: a claim for a benefit that is not                    30 calendar days
a pre-service claim.

Extensions of Time Frames
The time periods described in the chart may be extended, as follows:
         For urgent care claims: If Aetna does not have sufficient information to decide the
         claim, you will be notified as soon as possible (but no more than 24 hours after Aetna
         receives the claim) that additional information is needed. You will then have at least
         48 hours to provide the information. A decision on your claim will be made within
         48 hours after the additional information is provided.
         For non-urgent pre-service and post-service claims: The time frames may be
         extended for up to 15 additional days for reasons beyond the plan’s control. In this case,
         Aetna will notify you of the extension before the original notification time period has
         ended. If you fail to provide the information, your claim will be denied.
If an extension is necessary because Aetna needs more information to process your post-service
claim, Aetna will notify you and give you an additional period of at least 45 days after receiving
the notice to provide the information. Aetna will then inform you of the claim decision within 15
days after the additional period has ended (or within 15 days after Aetna receives the information,
if earlier). If you fail to provide the information, your claim will be denied.


Appeals
The plan has procedures for you to follow if you are dissatisfied with a decision that Aetna has
made.
Aetna will send you a written notice of an adverse benefit determination. The notice will give the
reason for the decision and will explain what steps you must take if you wish to appeal.
The notice will also tell you about your rights to receive additional information that may be
relevant to the appeal. Requests for an appeal must be made in writing within 180 days from the
receipt of the notice. However, appeals of adverse benefit determinations involving urgent care
may be made orally.
The plan provides for two levels of appeal. If are dissatisfied with the outcome of your level-one
appeal and wish to file a level-two appeal, your appeal must be filed no later than 60 days
following receipt of the level-one notice of an adverse benefit determination. The following chart
summarizes some information about how appeals are handled for different types of claims.




Claims                                                  32
               Type of Claim                         Level-One Appeal              Level-Two Appeal
 Urgent care claim: a claim for medical care or              36 hours                      36 hours
 treatment where delay could:
     seriously jeopardize your life or health, or   Review provided by Aetna      Review provided by Aetna
     your ability to regain maximum function; or     personnel not involved in     personnel not involved in
                                                    making the adverse benefit    making the adverse benefit
     subject you to severe pain that cannot be            determination.                determination.
     adequately managed without the
     requested care or treatment.
 Pre-service claim: a claim for a benefit that            15 calendar days            15 calendar days
 requires Aetna’s approval of the benefit in
 advance of obtaining medical care.                 Review provided by Aetna      Review provided by Aetna
                                                     personnel not involved in     personnel not involved in
                                                    making the adverse benefit    making the adverse benefit
                                                          determination.                determination.
 Concurrent care claim extension: a request         Treated like an urgent care   Treated like an urgent care
 to extend a previously approved course of            claim or a pre-service        claim or a pre-service
 treatment.                                          claim, depending on the       claim, depending on the
                                                          circumstances.                circumstances.
 Post-service claim: a claim for a benefit that           30 calendar days            30 calendar days
 is not a pre-service claim.
                                                    Review provided by Aetna      Review provided by Aetna
                                                     personnel not involved in     personnel not involved in
                                                    making the adverse benefit    making the adverse benefit
                                                          determination.                determination.
You may also choose to have another person (an authorized representative) make the appeal on
your behalf by providing written consent to Aetna. However, in the case of an urgent care claim
or a pre-service claim, a physician familiar with the case may represent you in the appeal.


Claim Fiduciary
For the purpose of section 503 of Title 1 of the Employee Retirement Income Security Act
(ERISA) of 1974, as amended, Aetna is a fiduciary with complete authority to review all denied
claims for benefits under the plan. This includes, but is not limited to, determining whether
hospital or medical treatment is, or is not, medically necessary. In exercising its fiduciary
responsibility, Aetna has discretionary authority to:
        Determine whether, and to what extent, you and your covered dependents are entitled to
        benefits; and
        Construe any disputed or doubtful terms of the plan.
Aetna has the right to adopt reasonable policies, procedures, rules and interpretations of the plan
to promote orderly and efficient administration. Aetna may not act arbitrarily and capriciously,
which would be an abuse of its discretionary authority.
Bayer Corporation is responsible for making the reports and disclosures required by ERISA,
including the creation, distribution and final content of:
        Summary plan descriptions;
        Summary of material modifications; and
        Summary annual reports.



                                                     33                                            Claims
Subrogation/Reimbursement
The plan has the right to subrogate claims. This means that the plan can recover:
        Any payments made as a result of an injury or illness caused by the action or fault of
        another person;
        A lawsuit settlement from payments made from any source, including automobile or
        homeowners insurance, whether yours or another’s; or
        Any payment made when any other third party is responsible for the condition giving rise
        to the medical expenses.
If you or your covered dependent receives benefits as the result of an illness or injury caused by
another party, the medical plan has the right to be reimbursed for those benefits from any
settlement or payment you receive from the person who caused the illness or injury. This
process is called subrogation.

Definitions
You need to understand these terms:
        A “covered person” includes, for the purposes of this provision, anyone on whose behalf
        the plan pays or provides any benefit, including (but not limited to) the minor child or
        dependant of any plan member or person entitled to receive any benefits from the plan.
        The term “responsible party” means any party actually, possibly, or potentially
        responsible for making any payment to a covered person due to that covered person’s
        injuries, illness, or condition. The term includes the liability insurer of the responsible
        party or any insurance coverage.
        “Insurance coverage” refers to any coverage providing medical expense or liability
        coverage, including (but not limited to):
           Uninsured motorist coverage;
           Underinsured motorist coverage;
           Personal umbrella coverage;
           Medical payment coverage;
           Workers’ compensation coverage;
           No-fault automobile insurance coverage; or
           Any first-party insurance coverage.

How Subrogation and Right of Recovery Works
Immediately upon paying or providing any benefit under this plan, the plan shall be subrogated to
(stand in the place of) all rights of recovery a covered person has against any responsible party
with respect to any payment made by the responsible party to a covered person due to the
person’s injuries, illness, or condition, to the full extent of benefits provided or to be provided by
the plan.
In addition, if a covered person receives any payment from any responsible party or insurance
coverage as a result of an injury, illness, or condition, the plan has the right to recover from, and
be reimbursed by, the covered person for all amounts this plan has paid and will pay as a result
of that injury, illness, or condition, up to and including the full amount the covered person receives
from all responsible parties.



Claims                                            34
The plan has an automatic lien, to the extent of benefits advanced for the treatment of the injury,
illness, or condition for which the responsible party is liable. The lien will be imposed upon any
recovery that a covered person receives from any responsible party or insurance coverage as a
result of an injury, illness, or condition, whether by settlement, judgment, or otherwise. The lien
may be enforced against any party who possesses funds or proceeds representing the amount of
benefits paid by the plan, including (but not limited to):
        The covered person;
        The covered person’s representative or agent;
        The responsible party;
        The responsible party’s insurer, representative, or agent; and/or
        Any other source possessing funds representing the amount of benefits paid by the plan.
By accepting benefits from the plan (whether the payment of the benefits is made to the covered
person or made on behalf of the covered person to any provider), the covered person agrees
that:
        If he or she receives any payment from any responsible party as a result of an injury,
        illness, or condition, he or she will serve as a constructive trustee over the funds that
        constitute such payment. Failure to hold such funds in trust will be deemed a breach of
        the covered person’s fiduciary duty to the plan.
        This plan’s recovery rights are a first-priority claim against all responsible parties and are
        to be paid to the plan before any other claim for damages. This plan shall be entitled to
        full reimbursement on a first-dollar basis from any responsible party’s payments, even if
        such payment to the plan will result in a recovery to the covered person that is insufficient
        to make him or her whole or to compensate him or her in part or in whole for the
        damages sustained. The plan is not required to participate in or pay court costs or
        attorney fees to any attorney hired by the covered person to pursue his or her damage
        claim.
        Any court proceeding with respect to this provision may be brought in any court of
        competent jurisdiction as the plan may elect. The covered person hereby submits to
        each such jurisdiction, waiving whatever rights may correspond to him or her by reason
        of his or her present or future domicile.
The covered person shall do nothing to prejudice the plan’s subrogation or reimbursement rights,
or to prejudice the plan’s ability to enforce the terms of this provision. This includes, but is not
limited to, refraining from making any settlement or recovery that attempts to reduce or exclude
the full cost of all benefits provided by the plan.
It is the duty of the covered person to:
        Fully cooperate with the plan’s efforts to recover benefits it paid.
        Notify the plan or the Claims Administrator within 30 days of the date when any notice is
        given to any party, including an attorney, of the intention to pursue or investigate a claim
        to recover damages or obtain compensation due to injuries or illness sustained by the
        covered person.
        Provide all information requested by the plan, the Claims Administrator or its
        representative, including (but not limited to) completing and submitting any applications,
        forms or statements requested by the plan.




                                                  35                                         Claims
Failure to provide this information may result in the termination of health benefits for the covered
person or in the institution of court proceedings against the covered person.
The terms of this entire subrogation and right of recovery provision shall apply, and the plan is
entitled to full recovery regardless of whether any liability for payment is admitted by any
responsible party and regardless of whether the settlement or judgment received by the covered
person identifies the medical benefits the plan provided or purports to allocate any portion of the
settlement or judgment to the payment of expenses other than medical expenses. The plan is
entitled to recover from any and all settlements or judgments, even those designated as pain and
suffering or non-economic damages only.
In the event any claim is made that any part of this subrogation and right of recovery provision is
ambiguous or questions arise concerning the meaning or intent of any of its terms, the plan or the
Claims Administrator shall have the sole authority and discretion to resolve all disputes regarding
the interpretation of this provision.
You are required to assist in this process and should not settle any claim without written consent
from Aetna.


  For more information, contact Aetna Member Services at the number shown on your ID card.




Claims                                           36
Glossary
In this section you’ll find definitions for the terms that appear in bold type in the text of this
booklet.

Behavioral Health Provider
A licensed organization or professional providing diagnostic, therapeutic or psychological services
for the treatment of mental health and substance abuse. Behavioral health providers include
hospitals, residential treatment facilities, psychiatric physicians, psychologists and social workers.

Brand-Name Drug
A prescription drug protected by trademark registration.

Copayment (copay)
The fee you must pay to an in-network provider at the time of service for certain covered
expenses and benefits, as shown in the Summary of Benefits.

Custodial Care
Services and supplies – including room and board and other institutional care – provided to help
you in the activities of daily life. Such services and supplies are considered custodial care, no
matter who prescribes, recommends or performs them.

Detoxification
The process whereby an alcohol-intoxicated, alcohol-dependent or drug-dependent person is
assisted in a facility licensed by the state in which it operates, through the period of time
necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or
drug dependent factor, or alcohol in combination with drugs as determined by a licensed
physician, while keeping physiological risk to the patient at a minimum.

Durable Medical Equipment
Equipment  and the accessories needed to operate it  that is:
        Made to withstand prolonged use;
        Made for and mainly used in the treatment of a disease or injury; and
        Suited for use in the home.

Effective Treatment of Alcoholism or Drug Abuse
A program of alcoholism or drug abuse therapy that is prescribed and supervised by a behavioral
health provider and either:

        Has a follow-up therapy program directed by a physician on at least a monthly basis; or
        Includes meetings at least once a month with organizations devoted to the treatment of
        alcoholism or drug abuse.




                                                   37                                         Glossary
Note: Maintenance care (providing an alcohol- and/or drug-free environment) and detoxification
are not considered “effective treatment.”

Effective Treatment of a Mental Disorder
A program that is:

        Prescribed by a behavioral health provider; and
        For a disorder that can be changed for the better.

Emergency Medical Condition
A recent and severe medical condition  including but not limited to severe pain  that would lead
a prudent layperson, possessing an average knowledge of medicine and health, to believe that
the condition, sickness or injury is of such a nature that failure to get immediate medical care
could result in:
        Placing the person’s health in serious jeopardy; or
        Serious impairment of bodily function; or
        Serious dysfunction of a body part or organ; or
        Serious jeopardy to the health of the fetus (in the case of a pregnant woman).

Experimental or Investigational
A drug, device, treatment or procedure is experimental or investigational if:
        It requires approval by a government authority, including the U.S. Food and Drug
        Administration (FDA), prior to use, but such approval has not been granted; or
        It is the subject of a written protocol used by any facility for research, clinical trials, or
        other tests or studies to evaluate is safety, effectiveness, toxicity or maximum tolerated
        dose, as evidenced in the protocol itself or in the written consent form used by the facility;
        or
        It is a type of drug, device or treatment that is the subject of a Phase I or Phase II clinical
        trial or the experimental or research arm of a Phase III clinical trial, as these Phases are
        defined in regulations and other official actions and publications of the FDA and the
        U.S. Department of Health and Human Services; or
        It has not been proved safe and effective under generally accepted standards of medical
        practice.
“Generally accepted standards of medical practice” means standards that are based on credible
scientific evidence published in peer-reviewed medical literature generally recognized by the
relevant medical community, or otherwise consistent with physician specialty society
recommendations and the views of physicians practicing in relevant clinical areas and any other
relevant factors.


 Examples of how this evidence is applied to specific treatments and conditions, called “Clinical
                      Policy Bulletins,” can be found on Aetna's website.




Glossary                                          38
Formulary
A list of prescription drugs that have been evaluated and selected by Aetna clinical pharmacists
for their therapeutic equivalency and efficacy. The formulary includes both brand-name drugs
and generic drugs and is periodically reviewed and modified by Aetna.

Generic Drug
A prescription drug that is not protected by trademark registration, but is produced and sold under
the chemical formulation name.

Home Health Care Plan
A plan that provides for care and treatment in a person’s home. It must be:
        Prescribed in writing by the attending physician; and
        An alternative to confinement in a hospital or convalescent facility.

Hospice Care
Care provided to a terminally ill person by or under arrangements with a hospice care agency.
The care must be part of a hospice care program.

Hospice Care Program
A written plan of hospice care that:
        Is established by and reviewed from time to time by the person’s attending physician and
        appropriate hospice care agency personnel;
        Is designed to provide palliative care (pain relief) and supportive care to terminally ill
        people and supportive care to their families; and
        Includes an assessment of the person’s medical and social needs and a description of
        the care to be given to meet those needs.

Hospital
A place that:
        Mainly provides inpatient facilities for the surgical and medical diagnosis, treatment, and
        care of injured and sick persons;
        Is supervised by a staff of physicians;
        Provides 24-hour-a-day RN service;
        Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, or a nursing
        home; and
        Charges for its services.




                                                  39                                        Glossary
Infertile
For a female who is:
        Under age 35, the inability to conceive after one year or more without contraception or
        after 12 cycles of artificial insemination.
        Age 35 or older, the inability to conceive after six months without contraception or after
        six cycles of artificial insemination.

In-Network Provider
A health care provider who has contracted with Aetna to furnish services or supplies for a
negotiated charge.

LPN
A licensed practical nurse.

Necessary
A necessary service is one that a physician, using prudent clinical judgment, would provide to a
patient to prevent, evaluate, diagnose or treat an illness, injury, disease or its symptoms.
It must be:
        Provided according to generally accepted standards of medical practice;
        Clinically appropriate, in terms of type, frequency, extent, site and duration, and
        considered effective for the patient’s illness, injury or disease;
        Not primarily for the convenience of the patient, physician or other health care provider;
        and
        Not more costly than an alternative service or services that are at least as likely to
        produce the same therapeutic or diagnostic results for the diagnosis or treatment of the
        patient’s illness, injury or disease.
For the purposes of this definition, “generally accepted standards of medical practice” means
standards based on credible scientific evidence published in peer-reviewed medical literature
recognized by the medical community.

Negotiated Charge
The maximum charge an in-network provider has agreed to make for any service or supply for
the purpose of benefits under this plan.

Non-Occupational Disease
A non-occupational disease is a disease that does not:
        Result from (or in the course of) any work for pay or profit; or
        Result in any way from a disease that does.
A disease will be considered non-occupational, regardless of its cause, if proof is provided that
the person:
        Is covered under any type of workers’ compensation law; and
        Is not covered for that disease under such law.



Glossary                                         40
Non-Occupational Injury
A non-occupational injury is an accidental bodily injury that does not:
        Result from (or in the course of) any work for pay or profit; or
        Result in any way from an injury that does.

Out-of-Network Provider
A health care provider who does not belong to Aetna’s network and has not contracted with Aetna
to furnish services or supplies at a negotiated charge.

Pharmacy
An establishment where prescription drugs are legally dispensed.

Physician
A legally qualified physician. The term “doctor” is also used throughout this booklet, and has the
same meaning as “physician.”

Prescription
This is a prescriber’s order for a prescription drug. If it is an oral order, it must be put promptly in
writing by the pharmacy.

Primary Care Physician (PCP)
An in-network physician who:
        Supervises, coordinates, and provides initial care and basic medical services as a
        general or family care practitioner or, in some cases, as an internist or a pediatrician, to
        plan participants;
        Initiates their referral for specialist care; and
        Maintains continuity of patient care.

RN
A registered nurse.

Referral
Specific written or electronic direction or instruction from a plan participant’s PCP, in conformance
with Aetna’s policies and procedures, which directs the plan participant to a participating provider
for medically necessary care.




                                                   41                                        Glossary
Retail Clinic
A free-standing health care facility that has contracted with Aetna to:
         Treat unscheduled and/or non-emergency illnesses and injuries; and
         Administer certain immunizations.
A retail clinic must:
         Provide unscheduled and/or non-emergency medical services;
         Make charges for the services provided;
         Be licensed and certified as required by any state or federal law or regulation;
         Be staffed by independent practitioners, such as Nurse Practitioners, licensed in the state
         where the clinic is located;
         Keep a medical record on each patient;
         Provide an ongoing quality assurance program;
         Have at least one physician on call at all times;
         Have a physician who sets protocol for clinical policies, guidelines and decisions; and
         Not be the emergency room or outpatient department of a hospital.

Room and Board Charges
Charges made by an institution for room and board and other necessary services and supplies.
The charges must be regularly made at a daily or weekly rate.
If a hospital or other health care facility doesn’t identify the specific amounts charged for room
and board charges and other charges, Aetna will assume that 40% of the total is the room and
board charge, and 60% is other charges.

Semi-Private Room Rate
This is the room and board charge that an institution applies to the majority of beds in its semi-
private rooms with two or more beds. If there are no such rooms, Aetna will figure the rate, which
will be the rate most commonly charged by similar institutions in the same geographic area.

Skilled Nursing Facility
An institution that:
         Is licensed to provide, and does provide, the following on an inpatient basis for persons
         convalescing from a disease or injury:
            Professional nursing care by an RN, or by an LPN directed by a full-time RN; and
            Physical restoration services to help patients to meet a goal of self-care in daily living
             activities;
         Provides 24-hour-a-day nursing care by licensed nurses directed by a full-time RN;
         Is supervised full-time by a physician or RN;
         Keeps a complete medical record on each patient;




Glossary                                          42
        Has a utilization review plan;
        Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for people who
        are mentally retarded, for custodial or educational care, or for the care of mental
        disorders; and
        Charges for its services.

Specialist
A specialist is a physician who practices in any generally accepted medical or surgical sub-
specialty, and provides care that is not considered routine medical care. A physician who
practices in such a sub-specialty and provides routine medical care that could be provided by a
PCP will not be considered a specialist for the purposes of applying this plan’s copay provisions.

Terminally Ill
A medical prognosis of six months or less to live.




                                                 43                                        Glossary
                 Aetna Select Plan
November, 2009       CCG 09-0861

				
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