HI GrpAg00010 02 1 CA

AETNA HEALTH OF CALIFORNIA INC.

Group agreement

The HMO agreement is by and between

AETNA HEALTH OF CALIFORNIA INC.

(Aetna, we, us, or our)

and

LIGHTING RESOURCES, INC.

(Contract holder, you, or your)

Group agreement number: 0801556

Effective date: January 01, 2019

This HMO agreement takes effect on the effective date if we have received your signed group 

application and the initial premium. It remains in force until terminated.

Term of the HMO agreement: The initial term shall be the 12 consecutive month period beginning on 

the effective date.

Subsequent terms shall be the 12 consecutive month period beginning 

with the renewal date.

Premium due dates: The effective date and the 1st day of each succeeding calendar month.

Signed at Aetna’s Home Office. 1385 East Shaw Ave, Fresno, CA 93710.

By:

Gregory S. Martino

Vice President

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Table of contents

Page

The HMO agreement............................................................................................3

If you want to discuss your coverage ...................................................................3

Glossary ................................................................................................................4

Premium ...............................................................................................................5

Fees for special services and assessments ...........................................................7

Some of our other responsibilities .......................................................................9

Some of your other requirements and responsibilities........................................9

Termination ........................................................................................................12

Intentional deception .........................................................................................14

Responsibility for conduct..................................................................................14

General provisions..............................................................................................15

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The HMO agreement

The HMO agreement consists of several documents taken together. These documents are:

 Your group application

 This group agreement

 The EOC(s) attached

 The schedule of benefits attached

 Any riders and amendments to the group agreement, the EOC, and the schedule of benefits

If you want to discuss your coverage

If you have questions about your coverage under the HMO agreement, or if you wish to discuss it, 

contact your agent. If you did not use an agent to purchase your coverage, or if you have additional 

questions, you may contact us at:

Aetna

1385 East Shaw Ave

Fresno, CA 93710 

1-800-445-5299

Please have your group agreement number available when you contact us. It is on the front page of this 

group agreement.

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Glossary

You will see some words in bold type in the HMO agreement. The bold type means we have defined 

those words. The definitions are in this section and in the Glossary section of the EOC.

Contract holder

LIGHTING RESOURCES, INC. and entities associated with it for purpose of coverage under this HMO 

agreement.

Covered person

An employee or a dependent of an employee for whom all of the following applies:

 The person is eligible for coverage as defined in the EOC

 The person has enrolled for coverage and paid any required premium contribution

 The person’s coverage has not ended

Dates:

Effective date

Date we first cover you under this HMO agreement.

Final rates and fees schedule effective date

Date stated on the Final rates and fees schedule.

Premium due date

The effective date and the 1st day of each succeeding calendar month.

Renewal date

Date that is 12 months after the effective date and each 12 month date thereafter.

Termination date

The date coverage ends according to the Termination section.

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Premium

Premium – rates and amount due

The premium rates are stated in the final rates and fees schedule. We will provide you with a new final 

rates and fees schedule if and when the premium rates change. Any new schedule will state its effective 

date.

We charge premium based on the premium rates in effect on the premium due date.

The premium due on any premium due date is the sum of the premium charges for the coverage we 

provide. When we calculate premium due, we will use our records to determine who is a covered 

person.

You owe premium for a covered person starting with the first premium due date on or after the day the 

person’s coverage starts. You stop paying premium for a covered person as of the first premium due 

date on or after the day the person’s coverage ends.

Premium – individual proration

Premium shall be paid in full for persons who are covered for an entire month beginning with the 

premium due date.

Premiums shall be adjusted as outlined below for persons whose:

 Coverage is effective on a day other than the first day of the billing month or 

 Coverage terminates on a day other than the last day of the billing month

If a person’s coverage starts between the 1

st through the 15th of the month, the premium for the whole 

month is due. If the coverage starts between the 16th through the 31st of the month, no premium is due 

for the month.

If a person’s coverage ends between the 1

st through the 15th of the month, no premium is due for that 

month. If the coverage ends between the 16th through the 31st of the month, the premium for the whole 

month is due.

Premium – changes in rates

We may change the premium rates as of a premium due date during the initial term only if:

 There is a change in factors that materially affects the risk we assumed with this coverage. We 

identify these factors in our rate quote to you

 There is a change in federal and state laws or regulations, or there is a judicial decision, that 

materially affects the cost of providing coverage

We may change the premium rates as of a premium due date during any subsequent term. 

We will provide 60 days prior written notice to you of any change in premium rates. 

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Premium – experience credit

We may declare an experience credit at the end of a plan year. We do not have to declare any 

experience credit.

If we declare an experience credit, we may return the amount of the credit to you:

 By electronic fund transfer

 By application of the amount to premium due in the current or succeeding plan year, or

 By any other manner that we and you agree to

We can require you to share an experience credit with your employees in a manner reasonably 

acceptable to us, as a condition of our giving the credit. If the sum of employee contributions for 

coverage exceeds the sum of premium paid less any experience credits, we will require you to apply at 

least the excess experience credit for the sole benefit of employees.

Premium – when due

Premium is due on the premium due date.

You have a payment grace period of 31 days immediately following the premium due date. The HMO 

agreement will remain in force during the grace period. If we have not received all premium due by the 

end of the grace period, this HMO agreement will automatically terminate at the end of the grace 

period.

Premium – how billed and paid

We may bill you electronically. You shall pay premium due by electronic fund transfer. Payment occurs 

when we receive good funds.

We may accept a partial payment but this does not waive our right to collect the entire amount due. 

Premium – overdue amounts

We may recover from you the costs of collecting any unpaid premium, including reasonable attorney 

fees and costs of suit. 

Premium – eligibility corrections 

We will retroactively drop a covered person from coverage and credit to you premium payments if:

 We billed you based on eligibility information you provided us

 The eligibility information included a person who was not eligible for coverage

 You request that we retroactively drop the person from coverage, and

 The person did not pay the required premium contribution for the period

Our credit of premium is limited to 2 month’s credit for a person whose loss of eligibility occurred more 

than 30 days before the date you notified us. We may reduce the credits by the amount of any benefit 

payments we may have made on behalf of such persons before you notified us that the person was not 

eligible for coverage.

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Your request that we retroactively drop coverage is your representation that the person did not pay the 

required premium contribution for the period.

We will retroactively cover eligible persons whom you did not include in the eligibility information you 

provided us. We will cover them retroactively no more than 30 days before the date you both notify us 

and pay all applicable past premium.

Premium – waiver

Payment of premiums

We may waive up to one month’s billed premium payments during any HMO agreement term.

The premium waiver will not apply for those employees :

 If after that month's premium has been billed, employees are added or removed from the plan 

coverage. 

 For that month of coverage, additional premium will be due or credited.

Repayment of the waived premium

We may require you to pay back the premium waived if the group agreement is terminated within 12 

months of your original effective date. We will give 10 days prior written notice to you of the 

requirement for the repayment of the waived premium.

Fees for special services and assessments

Special services

You may request that we provide special services beyond the routine administration of this HMO 

agreement. We will charge you a fee for each special service we provide. 

The special services are:

 Our billing you for amounts due in a non-electronic medium

 Our accepting payment of amounts due from you other than by electronic fund transfer. If you 

pay us by check, the check does not constitute payment until it is honored by a bank

 Our handling your check returned to us due to insufficient funds. We may return the check to 

you without a second attempt to cash it

 Reinstatement of the HMO agreement according to the Termination section

 Any other special service you request and we agree to provide

Special services – fees

The special service fees are stated in the final rates and fees schedule. We may change any fee on 30

days advance notice to you. We will provide you with a new final rates and fees schedule if and when 

the amount of any fee changes. The new schedule will state its effective date.

Assessments

We may charge you a pro rata allocation of any assessments we receive for state high risk pools and 

other state programs.

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Fees and assessments – when due

Fees and assessments are due on the premium due date immediately following our invoicing you.

You have a payment grace period of 31 days immediately following the premium due date. The HMO 

agreement will remain in force during the grace period. If we have not received all fees and assessments 

due by the end of the grace period, this HMO agreement will automatically terminate at the end of the 

grace period.

Fees and assessments – how billed and paid

We may bill you electronically. You shall pay fees and assessments by electronic fund transfer. Payment 

occurs when we receive good funds. 

We may accept a partial payment but this does not waive our right to collect the entire amount due.

Fees and assessments – overdue amounts

You shall pay us interest on the total amount of fees and assessments that is overdue. Overdue fees and 

assessments include amounts due but not yet paid during the grace period. The interest rate will be up 

to 1 1/2% per month for each month or partial month an amount due remains unpaid.

We may also recover from you the costs of collecting any unpaid fees and assessments, including 

reasonable attorney fees and costs of suit. 

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Some of our other responsibilities

We will prepare the EOC and schedule of benefits that are part of the HMO agreement, as required by 

applicable federal and state laws. We will provide them to you in electronic form. We will also provide 

them to you in paper form if you request it.

We will provide the coverage stated in the EOC and schedule of benefits that are part of the HMO 

agreement. We will administer the coverage as required by the HMO agreement and applicable federal 

and state laws.

We will protect the personal health information of covered persons as required by federal and state 

laws. We will use it and share it with others as needed for their care and treatment. We will also use and 

share it to help us process providers’ claims and otherwise help us administer the HMO agreement. For 

a copy of our Notice of Privacy Practices, call the toll-free Member Services number on your member ID 

card or log on to www.aetna.com.

Our duties in this Some of our other responsibilities section survive termination of the HMO agreement.

Some of your other requirements and responsibilities

Participation and contribution

You must comply with our participation and contribution requirements.

Distribution – certain Patient Protection and Affordable Care Act (ACA) 

requirements

You shall distribute two documents required by the federal ACA:

 Summary of benefits and coverage (SBC)

 Notices of material modifications

You shall distribute them to your employees and their dependents, in accordance with the federal 

delivery, timing, and trigger requirements.

You shall certify to us on an annual basis and upon our request, that you have distributed them and will 

distribute them consistent with the ACA. You shall give us your certification within 30 calendar days of 

our request.

You shall give us information or proof upon our request, that you have distributed them and will 

distribute them consistent with the ACA. The information or proof must be in a form we will accept. You 

shall give us the information or proof within 30 calendar days of our request.

Your duties and our rights in the ACA requirements provision survive termination of the HMO 

agreement.

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Distribution – certain Employee Retirement Income Security Act (ERISA) of 1974

requirements

You are responsible for creating and distributing all reports and disclosures required by ERISA. These 

include:

• Summary plan descriptions

• Summary of material modifications

• Summary annual reports

Distribution – EOC and schedule of benefits

You will distribute as required by applicable federal and state laws, the EOC and schedule of benefits 

that we provide you.

Information – access

You shall make payroll and other records directly related to a person's coverage under this HMO 

agreement available to us for inspection. This will occur:

 Upon our reasonable advance request

 At our expense

 At your office

 During regular business hours

Your duties and our rights in the Information – access provision survive termination of the HMO 

agreement.

Information – eligibility

You shall send us eligibility information we request to administer the HMO agreement. We will request 

the information monthly or as otherwise required. You will send us the information on our form, or 

through such other means as we require.

The eligibility information includes but is not limited to data needed to:

 Enroll your employees and their dependents

 Process terminations

 Make changes in family status

By sending the information to us you represent that it is correct. You acknowledge that we can and will 

rely on the information.

You shall:

 Maintain a reasonably complete record of the information you send us for at least seven years, 

and until the final rights and duties under the HMO agreement have been resolved.

 Send us information you sent us before, upon request.

We will not start covering a person under the HMO agreement until you send us the information to 

enroll that person. Subject to applicable federal and state laws and the HMO agreement, we will not 

stop covering a person until you send us the information to terminate coverage.

You shall notify us within 15 business days of the date in which:

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 An employee’s employment ceases, or

 A dependent loses eligibility under the HMO agreement

You must notify us when a request for retroactive termination is a result of a covered person:

 Performing an act or omission that constitutes fraud, or

 Making an intentional misrepresentation of material fact

to get coverage or to get a benefit under the HMO agreement.

Your duties and our rights in this Information – eligibility provision survive termination of the HMO 

agreement.

90 day waiting period limitation

Your plan can’t have a waiting period of more than 90 days. That means employees and their 

dependents must be able to begin health coverage within 90 days. This is a requirement of the 

Affordable Care Act. It applies both to you and to us. 

You will give us effective dates for your employees and their dependents that take into account all state 

and federal waiting period requirements. You acknowledge that we will rely on this information. You will 

inform us immediately if this information changes.

We will use this effective date information to enroll eligible employees and their dependents into the 

group plan.

Notices – termination of coverage

You shall notify covered persons in writing, of their rights when coverage stops.

In particular, you shall notify all eligible covered persons of their right to continue coverage pursuant to 

the Special coverage options after your plan coverage ends provisions in the EOC and applicable federal 

and state laws. Your notification will include:

 A description of plans available

 Premium rates

 Application forms

You will give the notification within 60 calendar days of a person becoming eligible for continuation 

coverage.

Your duties and our rights in this Notices – termination of coverage provision survive termination of the 

HMO agreement.

Workers’ compensation coverage

You must comply with workers’ compensation coverage laws applicable to your employees covered by 

the HMO agreement. Prior to the effective date and upon our request after the effective date you will 

provide us reasonable evidence of your satisfying applicable workers compensation coverage laws.

You will provide us with monthly reports of all workers’ compensation coverage cases. The report will 

list for each case, the employee name, identifying number, date of loss and diagnosis.

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Termination

Automatic termination

The HMO agreement and all coverage end as of the last day of the grace period if you have not paid us 

all premium due as of the beginning of the grace period. The grace period is described in the Premium

section.

The HMO agreement and all coverage end as of the last day of the grace period if you have not paid us 

all premiums and fees and assessments due as of the beginning of the grace period. The grace period is 

described in the Fees for special services and assessments section.

Termination by you

You may end coverage under this HMO agreement if you give us 30 days advance written notice. Your 

termination notice may apply to all classes or any class of your employees covered under the HMO 

agreement. You can send us a termination notice during a period for which you have paid premium, but 

your termination date must be after that period.

Termination by us

We may end the HMO agreement and all coverage it provides:

 Immediately upon notice to you:

- If you perform any act or practice that constitutes fraud or if you make any intentional 

misrepresentation of a material fact relevant to the coverage

- If you no longer have any employees under the plan who live, reside, or work in the service 

area

- If you are a member of an association and your membership in the association ceases

 Upon 30 days written notice to you:

- If you breach a provision of the HMO agreement and you do not cure the breach within the 

notice period

- If you cease to be a group as defined under applicable state law

- If you fail to meet our contribution or participation requirements applicable to this HMO 

agreement

- If you do not certify your compliance with our policies and procedures upon request

- If you change your eligibility or participation requirements without our consent

 Upon 90 days written notice to you (or such longer notice period as applicable federal and state 

laws requires,) if we cease to offer the product line provided by this HMO agreement

 Upon 180 days written notice to you (or such longer notice period as applicable federal and 

state laws requires,) if we act as required by applicable federal and state laws for uniform 

termination of coverage

We may rescind the HMO agreement and all coverage it provides for fraud or intentional 

misrepresentation of material fact upon 30 days advance written notice. The notice will state the 

effective date of rescission. You have the right to appeal our decision to rescind the HMO agreement 

and its coverage. Your appeal rights are:

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 You have the right to an Aetna appeal.

 You have the right to a third party review conducted by an independent external review 

organization.

Non-renewal for failure to respond

We may request that you tell us whether you intend to renew the HMO agreement. You must reply:

 Within two weeks of your receipt of the request or

 Within 15 days prior to the renewal date

whichever is later. Your reply must be in writing unless we authorize an oral reply. If you do not reply, 

we will continue coverage on and after the renewal date and you will owe premium. 

Effective time of termination

The HMO agreement and its coverage end at 11:59 p.m. on the day of termination.

Effect of termination

You, covered persons, and we continue to be responsible following termination for the duties we each 

incur prior to the termination of the HMO agreement. One of your duties includes payment of premium 

due for coverage through any grace period up to the day of termination. You, covered persons, and we 

also continue to be responsible for your, their, and our duties that the HMO agreement states are to 

occur following termination.

You, covered persons, and we have the rights and duties following termination of the HMO agreement, 

as stated specifically in the HMO agreement.

You shall notify covered persons of the termination of the HMO agreement. Your notice will comply 

with applicable federal and state laws. We have the right to notify employees of termination of the 

HMO agreement

Reinstatement

You may request that we reinstate the HMO agreement and coverage after we end it. You must make 

the request within 30 days of the termination date. We will reinstate the HMO agreement as of the 

termination date upon payment of all amounts due and you giving us reasonable assurances that you 

can and will fulfill all of your obligations under the HMO agreement.

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Intentional deception

If we learn that you or a covered person defrauded us or that a covered person intentionally 

misrepresented material facts, we can and may take actions that can have serious consequences for 

coverage. These serious consequences include, but are not limited to:

 Loss of coverage, starting at some time in the past. This is called rescission.

 Loss of coverage going forward

 Denial or termination of benefits

 Recovery of amounts we already paid

We also may report fraud to federal and state law enforcement. 

Rescission means you or a covered person loses coverage both going forward and going backward. If we 

paid claims for past coverage, we are entitled to the money back. 

You have special rights if we rescind all coverage under the HMO agreement:

 We will give you and your employees who are covered persons, 30 days advance written notice 

of any rescission of coverage.

 You have the right to an Aetna appeal.

 You have the right to a third party review conducted by an independent external review 

organization.

A covered person has special rights if we rescind coverage just for that individual: 

 We will give the covered person 30 days advance written notice of any rescission of coverage.

 The covered person has the right to an Aetna appeal.

 The covered person has the right to a third party review conducted by an independent external 

review organization.

Responsibility for conduct

Employees and agents

We are responsible to you for what our employees and other agents do. 

We are not responsible to you for what is done by others, such as providers. They are not our 

employees or agents. Providers in our network are what the federal and state laws call our independent 

contractors. That simply means we have a business relationship with them and they are not our 

employees or agents. 

Indemnification – in general

We agree to indemnify and hold you harmless against that portion of your liability to third parties as 

determined by a court of final jurisdiction or by binding arbitration caused directly by our willful 

misconduct, criminal conduct or material breach of this HMO agreement.

You agree to indemnify and hold us harmless against that portion of our liability to third parties as 

determined by a court of final jurisdiction or by binding arbitration caused directly by your negligence, 

breach of the HMO agreement, breach of applicable federal and state laws, willful misconduct, criminal 

conduct, fraud, or your breach of a fiduciary responsibility in the case of an action under ERISA, related 

to or arising out of this HMO agreement or your role as employer or Plan Sponsor, as defined by ERISA.

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These indemnification obligations end with the HMO agreement, except as to any matter concerning a 

claim that has been made in writing within 365 days after termination.

Indemnification – federal law requirements

You shall indemnify us and hold us harmless for our liability that is directly caused by your:

 Negligence

 Breach of the HMO agreement

 Breach of federal or state laws that apply or

 Willful misconduct

and your act or failure to act was related to or arose out of your obligation to deliver the Summary of 

benefits and coverage and Notices of material modification.

Your and our rights and duties in this Responsibility for conduct section survive termination of the HMO 

agreement.

General provisions

General provisions – content and interpretation of the HMO agreement

Applicable law

Applicable law means all federal and state laws that apply to the matters covered by the HMO 

agreement. Federal and state laws mean statutes, regulations, official agency direction and guidance, 

and judicial decisions and orders, as they may be passed or issued, or as they may be amended, from 

time to time.

Compliance with law

You and we shall interpret the HMO agreement if possible so it complies with applicable federal and 

state laws.

If the HMO agreement omits or misstates any right or duty under applicable federal and state laws, you 

and we shall implement the HMO agreement as though the right or duty is stated correctly in the HMO 

agreement.

If any provision of the HMO agreement is invalid or illegal, you and we shall implement the HMO 

agreement as though the provision is not in the HMO agreement.

Changes to the HMO agreement

The HMO agreement may be amended by a writing to which we both consent.

We may change or end some or all coverage under this HMO agreement by notice, if we act as required 

by applicable federal and state laws for uniform modification of coverage and uniform termination of 

coverage.

We may amend the HMO agreement by notice. We must give you 30 days advance written notice. Our 

amendment:

 Will not reduce benefits or coverage 

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 Will not eliminate benefits or coverage or

 Will not increase benefits or coverage with a concurrent increase in premium during the current 

HMO agreement term, other than increased benefits or coverage required by federal and state 

laws

Payment of the applicable premium on the effective date of any amendment is your consent to any 

amendment requiring your consent.

Changes to the HMO agreement do not require the consent of any employee or of any other person.

Entire agreement

The HMO agreement replaces and supersedes:

 All other prior agreements of HMO coverage between us

 Any other prior written or oral understandings, negotiations, discussions or arrangements 

between us related to this HMO coverage

Waiver

Only an officer of Aetna may waive a requirement of the HMO agreement.

We may fail to implement or fail to insist upon compliance with a provision of the HMO agreement at 

any given time or times. Our failure to implement or to insist on compliance is not a waiver of our right 

to implement or insist upon compliance with that provision at any other time or times.

General provisions – administration of the HMO agreement

Aetna name, symbols, trademarks and service marks

We control the use of our name and of our symbols, trademarks and service marks presently existing or 

subsequently established. You shall not use any of them in advertising or promotional materials or in 

any other way without our prior written consent. You shall stop any and all use immediately upon our 

direction or upon termination of the HMO agreement.

Assignment and delegation

You shall not assign any right or delegate any duty under the HMO agreement unless we approve it in 

writing in advance.

We may delegate some of our functions under the HMO agreement to third parties. We may also 

change or end these delegations. We do not need to give you advance notice to enter into, change or 

end these arrangements, and we do not need your consent.

Claim determinations – ERISA claim fiduciary

We are a fiduciary for the purpose of section 503 of Title 1 of the Employee Retirement Income Security 

Act of 1974. We have complete authority to review all denied claims for benefits under this HMO 

agreement. In exercising this fiduciary responsibility, we have discretionary authority:

 To determine whether and to what extent covered persons are entitled to benefits

 To construe any disputed or doubtful terms under the HMO agreement. We shall be deemed to 

have properly exercised our authority unless we abuse our discretion by acting arbitrarily and 

capriciously.

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Our review of claims for benefits may include the use of software and other tools to take into account 

factors such as:

 An individual’s claim history

 A provider’s billing patterns

 Complexity of the service or treatment

 Amount of time and degree of skill needed

 The manner of billing

Correcting our administrative errors

A clerical error in keeping records or a delay in making an entry will not alone determine whether there 

is coverage. We will determine the facts and decide if coverage is in force and its amount. We will make 

a fair adjustment in premium if correction of the error or delay changes coverage.

We may correct, withdraw, or replace the group agreement, any EOC, any schedule of benefits and any 

other document issued with an error or issued in error. 

Correcting your honest mistakes

If you or any employee makes an honest mistake of fact, we may make a fair change in premium. If the 

misstatement affects the existence or amount of coverage, we will use the true facts to determine 

whether coverage is or remains in effect and its amount.

Discrimination prohibited

You shall not encourage or discourage enrollment in the coverage provided by the HMO agreement 

based on health status or health risk.

You shall act so as not to discriminate unfairly between persons in like situations at the time of the 

action.

Notices

The HMO agreement requires or permits notice to each other. These notices shall be in writing.

Notice may be delivered:

 In person, and is effective upon delivery

 By United States mail, sent first class, postage prepaid, and is effective three U.S. Postal Service 

delivery days following the date of mailing

 By commercial carriers UPS and FedEx, effective upon delivery or

 By e-mail, facsimile or other electronic means, effective upon sending

Notice sent to us by mail and commercial carrier shall be sent to:

Aetna

1385 East Shaw Ave

Fresno, CA 93710 1-800-445-5299

Notice sent to you by mail and commercial carrier shall be sent to:

LIGHTING RESOURCES, INC.

805 E FRANSIC STREET

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ONTARIO, CA 91761

You and we must designate specific e-mail addresses, facsimile numbers or other electronic means in 

writing for purpose of notices.

Policies and procedures

We have the right to adopt reasonable policies, procedures, rules, and interpretations of the HMO 

agreement in order to promote orderly and efficient administration. You and all covered persons are 

bound by and shall comply with them. You will certify your compliance with them upon our request or 

as required specifically by the HMO agreement.

Third parties rights

This HMO agreement does not give any rights or impose any duties on third parties except as specifically 

stated.

Case 4:22-cv-00305-O Document 1-8 Filed 04/13/22 Page 18 of 152 PageID 44
Assistive Technology 

Persons using assistive technology may not be able to fully access the following information. 

For assistance, please call 1-888-982-3862.

Smartphone or Tablet 

To view documents from your smartphone or tablet, the free WinZip app is required. It may be 

available from your App Store.

Non-Discrimination 

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat 

people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language 

assistance. 

If you need a qualified interpreter, written information in other formats, translation or other 

services, call 1-888-982-3862.

If you believe we have failed to provide these services or otherwise discriminated based on a 

protected class noted above, you can also file a grievance with the Civil Rights Coordinator by 

contacting: 

Civil Rights Coordinator, 

P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 

1-800-648-7817, TTY: 711, 

Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, 

Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, 

or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, 

HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group 

of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and 

their affiliates (Aetna).

Case 4:22-cv-00305-O Document 1-8 Filed 04/13/22 Page 19 of 152 PageID 45
Language Assistance 

TTY: 711 

For language assistance in English call 1-888-982-3862 at no cost. (English)

Para obtener asistencia lingüística en español, llame sin cargo al 1-888-982-3862 . (Spanish)

欲取得繁體中文語言協助,請撥打1-888-982-3862,無需付費。(Chinese) 

Pour une assistance linguistique en français appeler le 1-888-982-3862 sans frais. (French)

Para sa tulong sa wika na nasa Tagalog, tawagan ang 1-888-982-3862 nang walang bayad. (Tagalog)

T’11 sh7 shizaad k’ehj7 bee sh7k1 a’doowo[ n7n7zingo Din4 k’ehj7koj8’ t’11 j77k’e h0lne’ 1-888-982-3862

(Navajo)

Benötigen Sie Hilfe oder Informationen in deutscher Sprache? Rufen Sie uns kostenlos unter der 

Nummer 1-888-982-3862 an. (German)

Për asistencë në gjuhën shqipe telefononi falas në 1-888-982-3862. (Albanian) 

በ አማርኛ የ ቋንቋ እገ ዛ ለማግኘትበ 1-888-982-3862 በነ ጻ ይደውሉ(Amharic)

)Acibar( .1-888-982-3862 ) ( 

Լեզվի ցուցաբերած աջակցության (հայերեն) զանգի 1-888-982-3862 առանց գնով: (Armenian)

Niba urondera uwugufasha mu Kirundi, twakure kuri iyi nomero 1-888-982-3862 ku busa. (BantuKirundi)

Alang sa pag-abag sa pinulongan sa (Binisayang Sinugboanon) tawag sa 1-888-982-3862 nga walay 

bayad. (Bisayan-Visayan) 

বাাংলায় ভাষা সহায়তার জন্য ববন্ামুল্লয 1-888-982-3862 -তত কল করুন্।(Bengali-Bangala)

Case 4:22-cv-00305-O Document 1-8 Filed 04/13/22 Page 20 of 152 PageID 46
Case 4:22-cv-00305-O Document 1-8 Filed 04/13/22 Page 21 of 152 PageID 47
Ɓɛ́m̀ ké gbo-kpá-kpá dyé pídyi ɖé Ɓǎsɔ́ɔ̀-wùɖùǔn wɛ̃ɛ, ɖá 1-888-982-3862 (Kru-Bassa)

)hsidruK( . 1-888-982-3862 

 , 1-888-982-3862

 

 . (Laotian)

 ( ) 1-888-982-3862 . (Marathi)

Ñan bōk jipañ ilo Kajin Majol, kallok 1-888-982-3862 ilo ejjelok wōnān. (Marshallese) 

Ohng palien sawas en soun kawewe ni omw lokaia Ponape koahl 1-888-982-3862 ni sohte isais. 

(Micronesian-Pohnpeian).

 1-888-982-3862 (Mon-Khmer, Cambodian)

( ) 1-888-982-3862 (Nepali)

Tën kuɔɔny ë thok ë Thuɔŋjäŋ cɔl 1-888-982-3862 kecïn aɣöc. (Nilotic-Dinka)

For språkassistanse på norsk, ring 1-888-982-3862 kostnadsfritt. (Norwegian)

Fer Helfe in Deitsch, ruf: 1-888-982-3862 aa. Es Aaruf koschtet nix. (Pennsylvanian Dutch)

)Persian( . 1-888-982-3862 

Aby uzyskać pomoc w języku polskim, zadzwoń bezpłatnie pod numer 1-888-982-3862 (Polish)

Para obter assistência linguística em português ligue para o 1-888-982-3862 gratuitamente. 

(Portuguese)

(Punjabi) , 1-888-982-3862 ‘ 

Pentru asistenţă lingvistică în româneşte telefonaţi la numărul gratuit 1-888-982-3862 (Romanian)

Чтобы получить помощь русскоязычного переводчика, позвоните по бесплатному номеру 1-888-

982-3862 . (Russian)

Mo fesoasoani tau gagana I le Gagana Samoa vala’au le 1-888-982-3862 e aunoa ma se totogi. (Samoan) 

Za jezičnu pomoć na hrvatskom jeziku pozovite besplatan broj 1-888-982-3862 . (Serbo-Croatian)

Fii yo on heɓu balal e ko yowitii e haala Pular noddee e oo numero ɗoo 1-888-982-3862 . Njodi woo 

fawaaki on. (Sudanic-Fulfulde)

Case 4:22-cv-00305-O Document 1-8 Filed 04/13/22 Page 22 of 152 PageID 48
Ukihitaji usaidizi katika lugha ya Kiswahili piga simu kwa 1-888-982-3862 bila malipo. (Swahili)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 1-888-982-3862 )cairyS-nairyssA( . 

 1-888-982-3862 . ( ) (Telugu) 

สํา หรับควํามช่วยเหลือทํางดํา้นภําษําเป็นภําษําไทย โทร 1-888-982-3862 ฟรีไม่มีค่ําใชจ้่ําย (Thai)

Kapau ‘oku fiema’u hā tokoni ‘i he lea faka-Tonga telefoni 1-888-982-3862 ‘o ‘ikai hā tōtōngi. 

(Tongan) 

Ren áninnisin chiakú ren (Kapasen Chuuk) kopwe kékkééri 1-888-982-3862 nge esapw kamé 

ngonuk. (Trukese-Chuukese) 

(Dil) çağrısı dil yardım için. Hiçbir ücret ödemeden 1-888-982-3862 . (Turkish)

Щоб отримати допомогу перекладача української мови, зателефонуйте за безкоштовним номером 

1-888-982-3862 . (Ukrainian)

 )udrU( 1-888-982-3862 

Để được hỗ trợ ngôn ngữ bằng (ngôn ngữ), hãy gọi miễn phí đến số 1-888-982-3862 . (Vietnamese)

)Yiddish( . 1-888-982-3862 

Fún ìrànlọwọ nípa èdè (Yorùbá) pe 1-888-982-3862 lái san owó kankan rárá. (Yoruba)

Case 4:22-cv-00305-O Document 1-8 Filed 04/13/22 Page 23 of 152 PageID 49
HI HCOC 4 CA 10

Health Maintenance Organization (HMO)

Evidence of Coverage

Prepared exclusively for

Contract holder: LIGHTING RESOURCES, INC.

Contract holder number: 0801556

HMO agreement effective date: January 01, 2019

Product Name: Aetna Value Network HMO

Underwritten by AETNA HEALTH OF CALIFORNIA INC. in the State of 

CALIFORNIA

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HI HCOC 4 CA 10

Welcome

Thank you for choosing Aetna.

This is your Evidence of Coverage, or EOC for short. It is one of three documents that together describe 

the benefits covered by your Aetna plan.

This EOC will tell you about your covered benefits – what they are and how you get them. The second 

document is the schedule of benefits. It tells you how we share expenses for eligible health services and 

tells you about limits – like when your plan covers only a certain number of visits.

The third document is the group agreement between Aetna Health of California Inc. (“Aetna”) and your 

contract holder. Ask your employer if you have any questions about the group agreement.

Oh, and each of these documents may have amendments or riders attached to them. They change or 

add to the documents they’re part of.

Where to next? Flip through the table of contents or try the Let’s get started! section right after it. Let's 

get started! section gives you a thumbnail sketch of how your plan works. The more you understand, the 

more you can get out of your plan. 

Welcome to your Aetna plan.

Some hospitals and other providers do not provide one or more of the following services that may be 

covered under your plan that includes:

 Family planning

 Contraceptive services, including emergency contraception

 Sterilization, including tubal ligation at the time of labor and delivery

 Infertility treatments

 Abortion

Call your prospective provider or refer to Let’s get started! – How to contact us for help section, if you 

have any questions. 

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HI HCOC 4 CA 10

Table of contents

Page

Welcome 

Let's get started ..........................................................................................................................6

Some notes on how we use words......................................................................................6

What your plan does – providing covered benefits............................................................6

How your plan works – starting and stopping coverage .....................................................6

How your plan works while you are covered ......................................................................6

How to contact us for help ..................................................................................................8

Your member ID card...........................................................................................................8

Who the plan covers...................................................................................................................9

Who is eligible .....................................................................................................................9

When you can join the plan.................................................................................................9

Who can be on your plan (who can be your dependents)..................................................9

Adding new dependents....................................................................................................10

Special times you and your dependents can join the plan................................................11

Medical necessity, referral and precertification requirements..............................................12

Medically necessary, medical necessity...........................................................................12

Referrals.............................................................................................................................12

Standing referrals..............................................................................................................12

Second opinion ..................................................................................................................12

Precertification..................................................................................................................13

Eligible health services under your plan ..................................................................................14

1. Preventive care and wellness........................................................................................14

2. Physicians and other health professionals....................................................................19

3. Hospital and other facility care ....................................................................................20

4. Emergency services and urgent care ............................................................................22

5. Specific conditions.........................................................................................................24

6. Specific therapies and tests...........................................................................................29

7. Other services...............................................................................................................32

What your plan doesn't cover - some eligible health service exceptions ...............................36

General exceptions............................................................................................................36

Additional exceptions for specific types of care................................................................41

1. Preventive care and wellness........................................................................................41

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HI HCOC 4 CA 10

2. Physicians and other health professionals...................................................................41

3. Hospital and other facility care .....................................................................................41

4. Emergency services and urgent care ...........................................................................42

5. Specific conditions.........................................................................................................42

6. Specific therapies and tests...........................................................................................43

7. Other services................................................................................................................44

Who provides the care..............................................................................................................46

Network providers............................................................................................................46

Your primary care physician (PCP)....................................................................................46

Keeping a provider you go to now (continuity of care) ....................................................48

What the plan pays and what you pay .....................................................................................49

The general rule.................................................................................................................49

Important exception - when your plan pays all.................................................................49

Special financial responsibility...........................................................................................49

Where your schedule of benefits fits in ............................................................................50

When you disagree - claim decisions and appeals procedures................................................50

Types of claims and communicating our claim decisions..................................................51

Adverse benefit determinations........................................................................................52

The difference between a complaint and an appeal.........................................................52

Appeals of adverse benefit determinations......................................................................52

Timeframes for deciding appeals......................................................................................53

Exhaustion of appeals process ..........................................................................................53

Independent medical review.............................................................................................54

Recordkeeping...................................................................................................................56

Fees and expenses.............................................................................................................56

Binding arbitration.............................................................................................................56

Coordination of benefits (COB).................................................................................................58

Key terms...........................................................................................................................58

Here's show COB works.....................................................................................................58

Determining who pays.......................................................................................................58

How COB works with Medicare.........................................................................................60

Other health coverage updates - contact information .....................................................61

Right to receive and release needed information.............................................................61

Right to pay another carrier ..............................................................................................62

Right of recovery ...............................................................................................................62

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HI HCOC 4 CA 10

When coverage ends ................................................................................................................63

When will your coverage end............................................................................................63

When will coverage end for any dependents....................................................................63

Why would we end you and your dependents coverage..................................................63

When will we send you a notice of your coverage ending?..............................................64

Special coverage options after your plan coverage ends.........................................................65

Consolidated Omnibus Budget Reconciliation Act (COBRA) Rights ..................................65

Continuation of coverage for other reasons.....................................................................68

A bit of this and that.................................................................................................................70

Administrative provisions..................................................................................................70

Coverage and services.......................................................................................................70

Honest mistakes and intentional deception......................................................................70

Some other money issues..................................................................................................71

Your health information ....................................................................................................72

Glossary.....................................................................................................................................73

Discount programs....................................................................................................................85

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HI HCOC 4 6 CA 10

Let’s get started!

Here are some basics. First things first – some notes on how we use words. Then we explain how your 

plan works. But for all the details – this is very important – you need to read this entire certificate and 

the schedule of benefits. And if you need help or more information, we tell you how to reach us. 

Some notes on how we use words

 When we say “you” and “your”, we mean both you and any covered dependents.

 When we say “us”, “we”, and “our”, we mean Aetna.

 Some words appear in bold type. We define them in the Glossary section.

Sometimes we use technical medical language that is familiar to medical providers. 

What your plan does – providing covered benefits

Your plan provides covered benefits. These are eligible health services for which your plan has the 

obligation to pay.

How your plan works – starting and stopping coverage

Your coverage under the plan has a start and an end. You start coverage after you complete the 

eligibility and enrollment process. To learn more see the Who the plan covers section.

Your coverage typically ends when you leave your job. Family members can lose coverage for many 

reasons, such as growing up and leaving home. To learn more see the When coverage ends section.

Ending coverage under the plan doesn’t necessarily mean you lose coverage with us. See the Special 

coverage options after your plan coverage ends section.

How your plan works while you are covered

Your HMO benefit plan:

 Helps you get and pay for a lot of – but not all – health care services. These are called eligible 

health services.

 Generally will pay only when you get care from providers in our network of doctors, hospitals, 

and other providers.

1. Eligible health services

Doctor and hospital services are the foundation for many other services. You’ll probably find the 

preventive care, emergency services and urgent condition coverage especially important. But 

the plan won't always cover the services you want. Sometimes it doesn't cover health care 

services your doctor will want you to have.

So what are eligible health services? They are health care services that meet these three 

requirements:

 They are listed in the Eligible health services under your plan section.

 They are not carved out in the What your plan doesn’t cover – some eligible health service

exceptions section. (We refer to this section as the “exceptions” section.)

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HI HCOC 4 7 CA 10

 They are not beyond any limits in the schedule of benefits.

2. Providers

Aetna’s network of doctors, hospitals and other health care providers are there to give you the 

care you need. You can find network providers and see important information about them most 

easily on our online provider directory. Just log into your secure member website at 

www.aetna.com.

You choose a primary care physician (we call that doctor your PCP) to oversee your care. Your 

PCP will provide your routine care, and send you to other providers when you need specialized 

care. Your plan often will pay a bigger share for eligible health services that you get through 

your PCP, so choose a PCP as soon as you can.

For more information about the network and the role of your PCP, see the Who provides the 

care section.

3. Service area

Your plan generally pays for eligible health services only within a specific geographic area, called 

a service area. There are some exceptions, such as for emergency services and urgent care. See 

the Who provides the care section. 

4. Paying for eligible health services– the general requirements

There are several general requirements for the plan to pay any part of the expense for an 

eligible health service. They are:

 The eligible health service is medically necessary, and

 You get your care from:

- Your PCP, or

- Another network provider after you get a referral from your PCP, and

 Your provider precertifies the eligible health service when required.

You will find details on medical necessity, referral and precertification requirements in the 

Medical necessity, referral and precertification requirements section. You will find the 

requirement to use a network provider and any exceptions in the Who provides the care

section.

5. Paying for eligible health services– sharing the expense

Generally your plan and you will share the expense of your eligible health services when you 

meet the general requirements for paying.

But sometimes your plan will pay the entire expense; and sometimes you will. For more 

information see the What the plan pays and what you pay section, and see the schedule of 

benefits.

6. Disagreements

We know that people sometimes see things differently.

The plan tells you how we will work through our differences. And if we still disagree, an 

Case 4:22-cv-00305-O Document 1-8 Filed 04/13/22 Page 30 of 152 PageID 56
HI HCOC 4 8 CA 10

independent group of experts called an “external review organization” or ERO for short, will 

make the final decision for us.

For more information see the When you disagree - claim decisions and appeals procedures 

section.

How to contact us for help

We are here to answer your questions. You can contact us by logging onto your secure member website

at www.aetna.com.

Register for Aetna's member website, our secure Internet access to reliable health information, tools 

and resources. Your member website online tools will make it easier for you to make informed decisions 

about your health care, view claims, research care and treatment options, and access information on 

health and wellness.

You can also contact us by:

 Calling Aetna Member Services at the toll-free number on your ID card

 Writing us at 1385 East Shaw Ave, Fresno, CA 93710

Your member ID card

Your member ID card tells doctors, hospitals, and other providers that you are covered by this plan. 

Show your ID card each time you get health care from a provider to help them bill us correctly and 

help us better process their claims.

Remember, only you and your covered dependents can use your member ID card. If you misuse your 

card we may end your coverage. 

We will mail you your ID card. If you haven’t received it before you need eligible health services, or 

if you’ve lost it, you can print a temporary ID card. Just log into your secure member website at 

www.aetna.com.

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Who the plan covers

You will find information in this section about:

 Who is eligible

 When you can join the plan

 Who can be on your plan (who can be your dependent)

 Adding new dependents

 Special times you and your dependents can join the plan

Who is eligible

Your employer decides and tells us who is eligible for health care coverage.

When you can join the plan

 As an employee you can enroll yourself and your dependents if you live or work in the service 

area: 

 At the end of any waiting period your employer requires

 Once each calendar year during the annual enrollment period 

 At other special times during the year (see the Special times you and your dependents can join 

the plan section below) 

If you do not enroll yourself and your dependents when you first qualify for health benefits, you may 

have to wait until the next annual enrollment period to join. 

Who can be on your plan (who can be your dependent)

You can enroll the following family members on your plan. (They are referred to in this EOC as your 

“dependents”.) 

 Your spouse 

 Your domestic partner

- You and your domestic partner will need to complete and sign a Declaration of Domestic 

Partnership with the California Secretary of State. Contact your employer for the form. To 

be eligible for coverage, a domestic partner must meet the following criteria: 

o He or she is your sole domestic partner and intend to remain so indefinitely

o He or she is not married or legally separated from anyone else

o He or she is not registered as a member of another domestic partnership within the 

past 6 months

o He or she is of the age of consent in your state of residence

o He or she is not a blood relative to a degree of closeness that would prohibit legal 

marriage in the state in which you legally reside

o He or she has cohabitated and resided with you in the same residence for the past 6 

months and intends to cohabitate and reside with you indefinitely

o He or she is engaged with you in a committed relationship of mutual caring and 

support, and is jointly responsible for your common welfare and living expenses

o He or she is not in the relationship solely for the purpose of obtaining the benefits 

of coverage

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HI HCOC 04 10 CA 20

o He or she can demonstrate interdependence with you by submitting proof of at 

least three of the following:

 Common ownership of real property (joint deed or mortgage agreement) or 

a common leasehold interest in property

 Common ownership of a motor vehicle

 Driver’s license with a common address

 Proof of joint bank accounts or credit accounts

 Proof of designation as the primary beneficiary for life insurance or 

retirement benefits or primary beneficiary designation under your will

 Assignment of a durable property power of attorney or health care power of 

attorney.

• Your dependent children – your own or those of your spouse or domestic partner

- The children must be under 26 years of age, and they include:

o Your biological children

o Your stepchildren

o Your legally adopted children

o Your foster children, including any children placed with you for adoption

o Any children you are responsible for under a qualified medical support order or courtorder (without regard to whether or not the child resides with you and whether or not 

the child resides inside the service area)

o Your grandchildren in your court-ordered custody

o A grandchild when his/her parent is already covered as a dependent under this plan

o Any other child with whom you have a parent-child relationship

You may continue coverage for a disabled child past the age limit shown above. See the Continuation of 

coverage for other reasons in the Special coverage options after your plan coverage ends section for 

more information.

Adding new dependents 

You can add the following new dependents any time during the year: 

• A spouse - If you marry, you can put your spouse on your plan. 

- We must receive your completed enrollment information not more than 60 days after 

the date of your marriage. 

- Ask your employer when benefits for your spouse will begin. It will be:

o No later than the first day of the first calendar month after the date we receive 

your completed enrollment information and

o Within 60 days of the date of your marriage.

• A domestic partner - If you enter a domestic partnership, you can enroll your domestic 

partner on your health plan. 

- We must receive your completed enrollment information not more than 60 days after 

the date you file a Declaration of Domestic Partnership, or not later than 60 days after you 

provide documentation required by your employer.

- Ask your employer when benefits for your domestic partner will begin. It will be either 

on the date your Declaration of Domestic Partnership is filed or the first day of the month 

following the date we receive your completed enrollment information.

• A newborn child - Your newborn child is covered on your health plan for the first 60 days

after birth. 

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HI HCOC 04 11 CA 20

- To keep your newborn covered, we must receive your completed enrollment 

information within 60 days of birth. 

- You must still enroll the child within 60 days of birth even when coverage does not 

require payment of an additional premium contribution for the covered dependent. 

- If you miss this deadline, your newborn will not have health benefits after the first 60 

days. 

• An adopted child - A child that you, or that you and your spouse or domestic partner adopts 

is covered on your plan for the first 60 days after the adoption is complete. 

- To keep your adopted child covered, we must receive your completed enrollment 

information within 60 days after the adoption. 

- If you miss this deadline, your adopted child will not have health benefits after the first 

60 days. 

• A stepchild - You may put a child of your spouse or domestic partner on your plan. 

- You must complete your enrollment information and send it to us within 60 days after 

the date of your marriage or your Declaration of Domestic Partnership with your stepchild’s 

parent. 

- Ask your employer when benefits for your stepchild will begin. It is either on the date of 

your marriage or the date your Declaration of Domestic Partnership is filed or the first day 

of the month following the date we receive your completed enrollment information. 

Notification of change in status

It is important that you notify us of any changes in your benefit status. This will help us effectively 

deliver your benefits. Please notify us as soon as possible of status changes such as:

 Change of address

 Change of covered dependent status

 Enrollment in Medicare or any other health plan of any covered dependent

Special times you and your dependents can join the plan 

You can enroll in these situations: 

• When you did not enroll in this plan before because: 

- You were covered by another group health plan, and now that other coverage has ended. 

- You had COBRA, and now that coverage has ended. 

- You or your dependents become eligible for State premium assistance under Medicaid or an 

S-CHIP plan for the payment of your premium contribution for coverage under this plan. 

• When a court orders you to cover a current spouse or a minor child on your health plan. 

We must receive your completed enrollment information from you within 31 days of that date on which 

you no longer have the other coverage mentioned above.

Effective date of coverage

Your coverage will be in effect the first day of the month following receipt of your completed enrollment 

application. 

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HI HCOC 04 12 CA 30

Medical necessity, referral and precertification requirements

The starting point for covered benefits under your plan is whether the services and supplies are eligible 

health services. See the Eligible health services under your plan and exceptions sections plus the 

schedule of benefits. 

Your plan pays for its share of the expense for eligible health services only if the general requirements 

are met. They are:

 The eligible health service is medically necessary, and

 You get your care from:

- Your PCP, or

- Another network provider after you get a referral from your PCP.

 Your provider precertifies the eligible health service when required.

This section addresses the medical necessity, referral and precertification requirements. You will find 

the requirement to use a network provider and any exceptions in the Who provides the care section.

Medically necessary; medical necessity

As we said in the Let's get started! section, medical necessity is a requirement for you to receive a 

covered benefit under this plan. 

The medical necessity requirements are stated in the Glossary section, where we define "medically 

necessary, medical necessity." That is where we also explain what our medical directors or their 

physician designees consider when determining if an eligible health service is medically necessary. 

Referrals

You need a referral from your physician, PCP for most eligible health services. If you do not have a 

referral when required, we won’t pay the provider. You will have to pay for services if your physician, 

PCP fails to ask us for the referral. You do not need a referral to see a network obstetrician (OB), 

gynecologist (GYN) or OB/GYN. Refer to the What the plan pays and what you pay section.

Standing referral

When you require a specialized medical or mental health care over a prolonged period of time, we will 

issue you a standing referral to a specialist. 

If we determine that your care should be coordinated by your specialist, we will:

 Authorize a standing referral for up to 12 months

 Make this decision within 3 business days of receiving the necessary information

Second opinion

You can also request a second opinion for a surgery or course of treatment recommended by your PCP

or provider. You will need to: 

 Go to a provider in your PCP’s affiliated medical group to obtain a second opinion for care by 

your PCP

 Go to a network provider to obtain a second opinion for care by a specialist

 Obtain the necessary precertification when required

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 If there is no such specialist in our network, we will refer you to an out-of-network provider

You should contact your PCP to request a referral for a second opinion.

If your request needs to be expedited because of your health, we will respond to your request for a 

second opinion within 72 hours. For more information regarding second opinions, including our 

timelines to respond, contact Member Services at the toll-free number on your ID card. 

Precertification

You need pre-approval from us for some eligible health services. Pre-approval is also called 

precertification.

Your physician or PCP is responsible for obtaining any necessary precertification before you get the 

care. If your physician or PCP doesn't get a required precertification, we won't pay the provider who 

gives you the care. You won't have to pay either if your physician or PCP fails to ask us for 

precertification. If your physician or PCP requests precertification and we refuse it, you can still get the 

care but the plan won’t pay for it. You will find details on requirements in the What the plan pays and 

what you pay - Important exceptions – when you pay all section.

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Eligible health services under your plan

The information in this section is the first step to understanding your plan's eligible health services.

Your plan covers many kinds of health care services and supplies, such as physician care and hospital

stays. But sometimes those services are not covered at all or are covered only up to a limit.

For example,

 Physician care generally is covered but physician care for cosmetic surgery is never covered. 

This is an exception (exclusion).

 Home health care is generally covered but it is a covered benefit only up to a set number of 

visits a year. This is a limitation.

You can find out about these exceptions in the exceptions section, and about the limitations in the 

schedule of benefits.

We've grouped the health care services below to make it easier for you to find what you're looking for.

1. Preventive care and wellness

This section describes the eligible health services and supplies available under your plan when you are 

well.

Important notes:

1. You will see references to the following recommendations and guidelines in this section:

• Advisory Committee on Immunization Practices of the Centers for Disease Control and 

Prevention

• United States Preventive Services Task Force

• Health Resources and Services Administration

 American Academy of Pediatrics/Bright Futures/Health Resources and Services 

Administration guidelines for children and adolescents

These recommendations and guidelines may be updated periodically. When these are updated, 

they will be applied to this plan. The updates will be effective on the first day of the calendar 

year, one year after the updated recommendation or guideline is issued.

2. Diagnostic testing will not be covered under the preventive care benefit. For those tests, you will 

pay the cost sharing specific to eligible health services for diagnostic testing.

3. Gender-Specific Preventive Care benefits include eligible health services described below 

regardless of the sex you were assigned at birth, your gender identity, or your recorded gender.

4. To learn what frequency and age limits apply to routine physical exams and routine cancer 

screenings, contact your physician or contact Member Services by logging on to your secure 

member website at www. aetna.com or at the toll-free number on your ID card. This information 

can also be found at the www.HealthCare.gov website.

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Routine physical exams

Eligible health services include office visits to your physician, PCP or other health professional for 

routine physical exams. This includes routine vision and hearing screenings given as part of the exam. A 

routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a 

suspected or identified illness or injury, and also includes:

 Evidence-based items that have in effect a rating of A or B in the current recommendations of 

the United States Preventive Services Task Force

 Services as recommended in the American Academy of Pediatrics/Bright Futures/Health 

Resources and Services Administration guidelines for children and adolescents.

 Screenings and counseling services as provided for in the comprehensive guidelines 

recommended by the Health Resources and Services Administration. These services may include 

but are not limited to:

- Screening and counseling services on topics such as:

o Interpersonal and domestic violence

o Sexually transmitted diseases

o Human Immune Deficiency Virus (HIV) infections

- Screening for gestational diabetes for women

- High risk Human Papillomavirus (HPV) DNA testing for women age 30 and older and limited 

to once every three years

 Radiological services, lab and other tests given in connection with the exam

 For covered newborns, an initial hospital checkup

Preventive care immunizations

Eligible health services include immunizations provided by your physician, PCP for infectious diseases 

recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control 

and Prevention.

Your plan does not cover immunizations that are not considered preventive care, such as those required 

due to your employment or travel.

Well woman preventive visits

Eligible health services include your routine:

 Well woman preventive exam office visit to your physician, PCP obstetrician (OB), gynecologist

(GYN) or OB/GYN. This includes Pap smears. Your plan covers the exams recommended by the 

Health Resources and Services Administration. A routine well woman preventive exam is a 

medical exam given for a reason other than to diagnose or treat a suspected or identified illness

or injury.

 Preventive care breast cancer (BRCA) gene blood testing by a physician and lab.

 Preventive breast cancer genetic counseling provided by a genetic counselor to interpret the 

test results and evaluate treatment.

Preventive screening and counseling services

Eligible health services include screening and counseling by your health professional for some 

conditions. These are obesity, misuse of alcohol and/or drugs, use of tobacco products, sexually 

transmitted infection counseling and genetic risk counseling for breast and ovarian cancer. Your plan will 

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cover the services you get in an individual or group setting. Here is more detail about those benefits.

 Obesity and/or healthy diet counseling

Eligible health services include the following screening and counseling services to aid in weight 

reduction due to obesity:

- Preventive counseling visits and/or risk factor reduction intervention

- Nutritional counseling

- Healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) 

and other known risk factors for cardiovascular and diet-related chronic disease

 Misuse of alcohol and/or drugs

Eligible health services include the following screening and counseling services to help prevent 

or reduce the use of an alcohol agent or controlled substance:

- Preventive counseling visits

- Risk factor reduction intervention

- A structured assessment

 Use of tobacco products

Eligible health services include the following screening and counseling services to help you to 

stop the use of tobacco products:

- Preventive counseling visits

- Treatment visits

- Class visits

Tobacco product means a substance containing tobacco or nicotine such as:

- Cigarettes

- Cigars

- Smoking tobacco

- Snuff

- Smokeless tobacco

- Candy-like products that contain tobacco

 Sexually transmitted infection counseling

Eligible health services include the counseling services to help you prevent or reduce sexually 

transmitted infections. 

 Genetic risk counseling for breast and ovarian cancer

Eligible health services include the counseling and evaluation services to help you assess 

whether or not you are at increased risk for breast and ovarian cancer.

Routine cancer screenings

Eligible health services include the following routine cancer screenings:

 Mammograms

 Prostate specific antigen (PSA) tests

 Digital rectal exams

 Fecal occult blood tests

 Sigmoidoscopies

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 Double contrast barium enemas (DCBE)

 Colonoscopies which includes removal of polyps performed during a screening procedure, and a 

pathology exam on any removed polyps

 Lung cancer screenings

These benefits will be subject to any age, family history and frequency guidelines that are:

 Evidence-based items or services that have in effect a rating of A or B in the recommendations 

of the United States Preventive Services Task Force

 Evidence-informed items or services provided in the comprehensive guidelines supported by the 

Health Resources and Services Administration

If you need a routine gynecological exam performed as part of a cancer screening, you may go directly 

to a network OB, GYN or OB/GYN without a referral. 

Prenatal care

Eligible health services include your routine prenatal physical exams as preventive care, which is the 

initial and subsequent history and physical exam such as:

 Maternal weight

 Blood pressure

 Fetal heart rate check

 Fundal height

Eligible health services also include participation in the California Prenatal Screening Program. The State 

Department of Health Services administers this program. 

You can get this care at your physician's, PCP’s, OB's, GYN's, or OB/GYN’s office.

Important note:

You should review the benefit under Eligible health services under your plan- Maternity and related 

newborn care and the exception sections of this EOC for more information on coverage for 

pregnancy expenses under this plan.

Comprehensive lactation support and counseling services

Eligible health services include comprehensive lactation support (assistance and training in breast 

feeding) and counseling services during pregnancy or at any time following delivery for breast-feeding.

Your plan will cover this when you get it in an individual or group setting. Your plan will cover this 

counseling only when you get it from a certified lactation support provider.

Breast feeding durable medical equipment

Eligible health services include renting or buying durable medical equipment you need to pump and 

store breast milk as follows:

Breast pump

Eligible health services include:

 Renting a hospital grade electric pump while your newborn child is confined in a hospital.

 The buying of:

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- An electric breast pump (non-hospital grade). Your plan will cover this cost once every three 

years, or

- A manual breast pump. Your plan will cover this cost once per pregnancy.

If an electric breast pump was purchased within the previous three year period, the purchase of another 

electric breast pump will not be covered until a three year period has elapsed since the last purchase.

Breast pump supplies and accessories

Eligible health services include breast pump supplies and accessories. These are limited to only one 

purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new 

pump.

Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same 

or similar purpose. Including the accessories and supplies needed to operate the item. You are 

responsible for the entire cost of any additional pieces of the same or similar equipment you purchase 

or rent for personal convenience or mobility.

Family planning services – female contraceptives 

Eligible health services include family planning services such as:

Counseling services

Eligible health services include education, counseling services and management of side effects 

provided by a physician, PCP, OB, GYN, or OB/GYN on contraceptive methods. These will be covered

when you get them in either a group or individual setting.

Devices

Eligible health services include contraceptive devices (including any follow-up services, 

management of side effects and device insertion and removal) when they are provided by a 

physician during an office visit.

Voluntary sterilization

Eligible health services include charges billed separately by the provider for female voluntary 

sterilization procedures and related services and supplies. This also could include tubal ligation and 

sterilization implants.

Important note:

See the following sections for more information:

 Family planning services - other

 Maternity and related newborn care

 Outpatient prescription drugs

 Treatment of basic infertility

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2. Physicians and other health professionals

Physician services

Eligible health services include services by your physician to treat an illness or injury. You can get those 

services:

 At the physician’s office

 In your home

 In a hospital

 From any other inpatient or outpatient facility

 By way of telemedicine

Important note:

Your plan covers telemedicine only when you get your telephone or internet-based consult through 

an authorized internet service vendor who conducts telemedicine consultations that has contracted 

with Aetna to offer these services. DocFind® tells you who those are. Telemedicine is not the same 

as an office visit and may have different cost sharing. See the schedule of benefits for specific plan 

details.

Other services and supplies that your physician may provide:

 Allergy testing and allergy injections

 Radiological supplies, services, and tests

Physician surgical services

Eligible health services include the services of:

 The surgeon who performs your surgery

 Your surgeon who you visit before and after the surgery

 Another surgeon who you go to for a second opinion before the surgery

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3. Hospital and other facility care

Hospital care

Eligible health services include inpatient and outpatient hospital care.

The types of hospital care services that are eligible for coverage include:

 Room and board charges up to the hospital’s semi-private room rate. Your plan will cover the 

extra expense of a private room when appropriate because of your medical condition.

 Services of physicians employed by the hospital

 Operating and recovery rooms

 Intensive or special care units of a hospital

 Administration of blood and blood derivatives, but not the expense of the blood or blood 

product

 Radiation therapy

 Cognitive rehabilitation 

 Speech therapy, physical therapy and occupational therapy 

 Oxygen and oxygen therapy

 Radiological services, laboratory testing and diagnostic services

 Medications

 Intravenous (IV) preparations

 Discharge planning

 Services and supplies provided by the outpatient department of a hospital,

Anesthesia and hospital charges for dental care

Eligible health services include anesthesia for dental care only if you: 

 Have a disability or condition that requires a dental procedure be done in a hospital or 

outpatient surgery center

 Are developmentally disabled

 Are in poor health and have a medical need for general anesthesia

 Are under 7 years old

Alternatives to hospital stays

Outpatient surgery and physician surgical services

Eligible health services include services provided and supplies used in connection with outpatient 

surgery performed in a surgery center or a hospital’s outpatient department.

Important note:

Some surgeries can be done safely in a physician’s office. For those surgeries, your plan will pay only 

for physician, PCP services and not for a separate fee for facilities.

Home health care

Eligible health services include home health care services provided by a home health agency in the 

home, but only when all of the following criteria are met: 

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 You are homebound.

 Your physician orders them.

 The services take the place of your needing to stay in a hospital or a skilled nursing facility, or 

needing to receive the same services outside your home.

 The services are a part of a home health care plan.

 The services are skilled nursing services, home health aide services or medical social services, or 

are short-term speech, physical or occupational therapy.

 If you are discharged from a hospital or skilled nursing facility after a stay, the intermittent 

requirement may be waived to allow coverage for continuous skilled nursing services. See the 

schedule of benefits for more information on the intermittent requirement.

 Home health aide services are provided under the supervision of a registered nurse.

 Medical social services are provided by or supervised by a physician or social worker.

Short-term physical, speech and occupational therapy provided in the home are subject to the 

conditions and limitations imposed on therapy provided outside the home. See the Short-term 

rehabilitation services and Habilitation therapy services sections and the schedule of benefits.

Home health care services do not include custodial care.

Hospice care

Eligible health services include inpatient and outpatient hospice care when given as part of a hospice 

care program. 

The types of hospice care services that are eligible for coverage include:

 Room and board

 Services and supplies furnished to you on an inpatient or outpatient basis

 Services by a hospice care agency or hospice care provided in a hospital

 Bereavement counseling

 Respite care

Hospice care services provided by the providers below may be covered, even if the providers are not an 

employee of the hospice care agency responsible for your care:

 A physician for consultation or case management

 A physical or occupational therapist

 A home health care agency for: 

- Physical and occupational therapy

- Medical supplies

- Outpatient prescription drugs

- Psychological counseling

- Dietary counseling

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Skilled nursing facility

Eligible health services include inpatient skilled nursing facility care.

The types of skilled nursing facility care services that are eligible for coverage include:

 Room and board, up to the semi-private room rate 

 Services and supplies that are provided during your stay in a skilled nursing facility

For your stay in a skilled nursing facility to be eligible for coverage, the following conditions must be 

met:

 The skilled nursing facility admission will take the place of:

- An admission to a hospital or sub-acute facility.

- A continued stay in a hospital or sub-acute facility.

 There is a reasonable expectation that your condition will improve enough to go home within a 

reasonable amount of time.

 The illness or injury is severe enough to require constant or frequent skilled nursing care on a 

24-hour basis.

4. Emergency services and urgent care

Eligible health services include services and supplies for the treatment of an emergency medical

condition or an urgent condition. 

As always, you can get emergency care from network providers. However, you can also get emergency 

care from out-of-network providers.

Your coverage for emergency services and urgent care from out-of-network providers ends when 

Aetna and the attending physician determine that you are medically able to travel or to be 

transported to a network provider if you need more care. 

You are covered for follow-up care only when your physician, PCP provides or coordinates it.

In case of a medical emergency

When you experience an emergency medical condition, you should go to the nearest emergency room. 

You can also dial 911 or your local emergency response service for medical and ambulance assistance. If 

possible, call your physician, PCP but only if a delay will not harm your health.

Non-emergency condition

If you go to an emergency room for what is not an emergency medical condition, the plan may not 

cover your expenses. See the schedule of benefits and the exception- Emergency services and urgent 

care section for specific plan details.

In case of an urgent condition

Urgent condition within the service area 

If you need care for an urgent condition while within the service area, you should first seek care 

through your physician, PCP. If your physician, PCP is not reasonably available to provide services, you 

may access urgent care from a network urgent care facility within the service area.

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Urgent condition outside the service area 

You are covered for urgent care obtained from a facility outside of the service area if you are 

temporarily absent from the service area and getting the health care service cannot be delayed until 

you return to the service area.

Non-urgent care

If you go to an urgent care facility for what is not an urgent condition, the plan may not cover your 

expenses. See the exception –Emergency services and urgent care section and the schedule of benefits

for specific plan details.

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5. Specific conditions

Gender reassignment

Eligible health services include, but are not limited to, the following services: 

 Hormone therapy

 Hysterectomy

 Mastectomy

 Vocal training

These services will not be denied if you enrolled as a member of the opposite sex or are in the process 

of a gender transition.

Diabetic equipment, supplies and education 

Eligible health services include:

 Services and supplies:

- Foot care to minimize the risk of infection 

- Insulin preparations

- Diabetic needles and syringes

- Injection aids for the blind

- Diabetic test agents

- Lancets/lancing devices

- Prescribed oral medications whose primary purpose is to influence blood sugar

- Alcohol swabs

- Injectable glucagons

- Glucagon emergency kits

 Equipment:

- External insulin pumps 

- Blood glucose monitors without special features, unless required due to blindness

 Training:

- Self-management training provided by a health care provider certified in diabetes selfmanagement training

This coverage is for the treatment of insulin (type I), non-insulin dependent (type II) diabetes and the 

treatment of elevated blood glucose levels during pregnancy.

Family planning services – other

Eligible health services include certain family planning services provided by your physician such as:

 Voluntary sterilization for males

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Maternity and related newborn care 

Eligible health services include prenatal and postpartum care and obstetrical services. After your child is 

born, eligible health services include:

 48 hours of inpatient care in a network hospital after a vaginal delivery

 96 hours of inpatient care in a network hospital after a cesarean delivery

 A shorter stay, if the attending physician, with the consent of the mother, discharges the 

mother or newborn earlier

 The mother could be discharged earlier. If so, the plan will pay for 2 post-delivery home visits by 

a health care provider.

Coverage also includes the services and supplies needed for circumcision by a provider.

Mental health treatment 

Eligible health services include the treatment of mental disorders, including that are defined as severe 

mental illnesses and/or serious emotional disturbances of a child, and that are provided by a hospital, 

psychiatric hospital, residential treatment facility, physician or behavioral health provider as follows:

• Inpatient room and board at the semi-private room rate, and other services and supplies 

related to your condition that are provided during your stay in a hospital, psychiatric hospital, 

or residential treatment facility.

• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric 

hospital or residential treatment facility, including:

- Office visits to a physician or behavioral health provider such as a psychiatrist, 

psychologist, social worker, or licensed professional counselor (includes telemedicine

consultation).

- All other outpatient mental health treatment, including:

- Partial hospitalization treatment provided in a facility or program for mental 

health treatment provided under the direction of a physician

- Intensive outpatient program provided in a facility or program for mental 

health treatment provided under the direction of a physician

- Electro-convulsive therapy (ECT)

- Monitoring of and the administration of injectable medications

- Behavioral health treatment for pervasive developmental disorder or autism 

- Skilled behavioral health services provided in the home

- Psychological and neuropsychological testing done by a physician or behavioral 

health provider such as psychiatrist, psychologist, social worker, or licensed 

professional counselor

- Transcranial Magnetic Stimulation (TMS)

Severe mental illness means the following:

 Anorexia/bulimia nervosa

 Bipolar disorder

 Major depressive disorder

 Obsessive compulsive disorder

 Panic disorder

 Pervasive developmental disorder (including autism)

 Psychotic disorders/delusional disorder

 Schizo-affective disorder

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 Schizophrenia 

A child suffering from serious emotional disturbances means a child who: 

 Has one or more mental disorders as identified in the most recent edition of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association 

(other than a primary substance use disorder or developmental disorder)

 Has inappropriate behavior for the child’s age according to expected developmental norms

 Meets the criteria in California’s Welfare and Institutions Code

Behavioral health treatment means professional services and treatment programs, including applied 

behavior analysis and evidence-based behavior intervention programs that develop or restore the 

functioning of any individual with pervasive developmental disorder or autism. Behavioral health 

treatment must:

 Be prescribed by a physician or psychologist 

 Be provided under a treatment plan prescribed by a qualified autism service provider

 Be administered by qualified autism service providers, qualified autism service professionals or 

qualified autism service paraprofessionals

The treatment plan must:

 Have measurable goals

 Be reviewed at least every six months

 Change whenever appropriate

 Describe the conditions that need to be treated

 Include the service type, number of hours, and parent participation needed

 End when treatment goals are met or no longer appropriate

A treatment plan is not used for custodial care or educational services. We can ask for a copy of the 

treatment plan. 

The following services require precertification: 

 Behavioral health treatment for pervasive developmental disorder or autism

 Inpatient admissions

 Intensive outpatient programs

 Neuropsychological testing

 Partial hospitalization treatment

 Psychological testing

 Residential treatment facility admissions

 Skilled behavioral health services provided in the home

Important note:

You may still be eligible for services under state law, including the Lanterman Developmental 

Disabilities Services Act, California Early Intervention Services Act, and services delivered as part 

of an individualized education program for individuals with exceptional needs.

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Important note:

Your plan covers telemedicine only when you get your telephone or internet-based consult 

through an authorized internet service vendor who conducts telemedicine consultations that has 

contracted with Aetna to offer these services. DocFind® tells you who those are. 

Substance related disorders treatment 

Eligible health services include the treatment of substance abuse provided by a hospital, psychiatric 

hospital, residential treatment facility, physician or behavioral health provider as follows:

• Inpatient room and board at the semi-private room rate and other services and supplies that 

are provided during your stay in a hospital, psychiatric hospital or residential treatment 

facility. Treatment of substance abuse in a general medical hospital is only covered if you are 

admitted to the hospital’s separate substance abuse section or unit, unless you are admitted for 

the treatment of medical complications of substance abuse.

As used here, “medical complications” include, but are not limited to, detoxification, electrolyte 

imbalances, malnutrition, cirrhosis of the liver, delirium tremens and hepatitis.

• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric 

hospital or residential treatment facility, including:

- Office visits to a physician or behavioral health provider such as a psychiatrist, 

psychologist, social worker, or licensed professional counselor (including telemedicine 

consultation).

- All other outpatient substance related disorders treatment, including:

- Outpatient detoxification

- Ambulatory detoxification, which is an outpatient service that monitors 

withdrawal from alcohol or other substance abuse, and may include 

administration of medications

- Partial hospitalization treatment (also known as day treatment) provided in a 

facility or program for treatment of substance abuse provided under the 

direction of a physician

- Intensive outpatient program provided in a facility or program for treatment of 

substance abuse provided under the direction of a physician

- Monitoring of and the administration of injectable medications

- Treatment of withdrawal symptoms

- Skilled behavioral health services provided in the home 

The following services require precertification: 

 Inpatient admissions

 Intensive outpatient programs

 Outpatient detoxification

 Partial hospitalization treatment 

 Residential treatment facility admissions

 Skilled behavioral health services provided in the home

Important note: 

Your plan covers telemedicine only when you get your telephone or internet-based consult through an 

authorized internet service vendor who conducts telemedicine consultations that has contracted with 

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Aetna to offer these services. DocFind® tells you who those are.

Reconstructive surgery and supplies

Eligible health services include reconstructive surgery by your provider and related supplies provided in 

an inpatient or outpatient setting only in the following circumstances:

 Your surgery reconstructs the breast where a necessary mastectomy was performed, such as an 

implant and areolar reconstruction. It also includes surgery on a healthy breast to make it 

symmetrical with the reconstructed breast and physical therapy to treat complications of the 

mastectomy, including lymphedema. Your physician will determine how long you stay in the 

hospital following your mastectomy. 

 Your surgery corrects or repairs abnormal structures of the body caused by: 

o Congenital defects

o Developmental abnormalities

o Trauma

o Infection

o Tumors

o Disease

o Cleft palate, cleft lip, or other craniofacial anomalies associated with cleft palate

 Your surgery will improve function or create a normal appearance.

 There are no other more appropriate surgical procedures

 Your surgery offers more than a minimal improvement in your appearance. 

Transplant services 

Eligible health services include organ transplant services provided by a physician and hospital only 

when we precertify them. 

Organ means:

 Solid organ

 Hematopoietic stem cell

 Bone marrow

Network of transplant specialist facilities

The amount you will pay for covered transplant services is determined by where you get transplant 

services. You can get transplant services from:

 An Institutes of ExcellenceTM (IOE) facility we designate to perform the transplant you need.

The National Medical Excellence Program® will coordinate all solid organ and bone marrow transplants, 

and other specialized care you need.

Treatment of basic infertility 

Eligible health services include basic infertility care, including seeing a network provider to diagnose 

the underlying medical cause of infertility and any surgery needed to treat the underlying medical cause 

of infertility.

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6. Specific therapies and tests

Outpatient diagnostic testing

Diagnostic complex imaging services

Eligible health services include complex imaging services by a provider, including:

 Computed tomography (CT) scans

 Magnetic resonance imaging (MRI) including magnetic resonance spectroscopy (MRS), magnetic 

resonance venography (MRV) and magnetic resonance angiogram (MRA)

 Nuclear medicine imaging including positron emission tomography (PET) scans

 Other outpatient diagnostic imaging service where the billed charge exceeds $500.

Complex imaging for preoperative testing is covered under this benefit.

Diagnostic lab work and radiological services

Eligible health services include diagnostic radiological services (other than diagnostic complex 

imaging), lab services, and pathology and other tests, but only when you get them from a 

licensed radiological facility or lab.

Chemotherapy 

Eligible health services for chemotherapy depend on where treatment is received. In most cases, 

chemotherapy is covered as outpatient care. However, your hospital benefit covers the initial dose of 

chemotherapy after a cancer diagnosis during a hospital stay.

Outpatient infusion therapy 

Eligible health services include infusion therapy you receive in an outpatient setting including but not 

limited to:

 A free-standing outpatient facility

 The outpatient department of a hospital

 A physician in his/her office

 A home care provider in your home

You can access the list of preferred infusion locations by contacting Member Services by logging onto 

your secure member website at www.aetna.com or calling the number on the back of your ID card.

Infusion therapy is the parenteral (i.e. intravenous) administration of prescribed medications or 

solutions. 

Certain infused medications may be covered under the outpatient prescription drug rider. You can 

access the list of specialty prescription drugs by contacting Member Services or by logging onto your 

secure member website at www.aetna.com or calling the number on the back of your ID card to 

determine if coverage is under the outpatient prescription drug rider or this EOC. 

When Infusion therapy services and supplies are provided in your home, they will not count toward any 

applicable home health care maximums.

Outpatient radiation therapy

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Eligible health services include the following radiology services provided by a health professional:

 Radiological services

 Gamma ray

 Accelerated particles

 Mesons

 Neutrons

 Radium

 Radioactive isotopes

Short-term cardiac and pulmonary rehabilitation services 

Eligible health services include the cardiac and pulmonary rehabilitation services listed below. 

Cardiac rehabilitation 

Eligible health services include cardiac rehabilitation services you receive at a hospital, skilled nursing 

facility or physician’s office, but only if those services are part of a treatment plan determined by your 

risk level and ordered by your physician.

Pulmonary rehabilitation 

Eligible health services include pulmonary rehabilitation services as part your inpatient hospital stay if it 

is part of a treatment plan ordered by your physician.

A course of outpatient pulmonary rehabilitation may also be eligible for coverage if it is performed at a 

hospital, skilled nursing facility, or physician’s office, is used to treat reversible pulmonary disease 

states, and is part of a treatment plan ordered by your physician.

Short-term rehabilitation services 

Short-term rehabilitation services help you restore or develop skills and functioning for daily living.

Eligible health services include short-term rehabilitation services your physician prescribes. The services 

have to be performed by:

 A licensed or certified physical, occupational or speech therapist 

 A hospital, skilled nursing facility, or hospice facility

 A home health care agency

 A physician

Short-term rehabilitation services have to follow a specific treatment plan, ordered by your physician.

Outpatient cognitive rehabilitation, physical, occupational, and speech therapy 

Eligible health services include: 

 Physical therapy, but only if it is expected to significantly improve or restore physical functions 

lost as a result of an acute illness, injury or surgical procedure.

 Occupational therapy (except for vocational rehabilitation or employment counseling), but only 

if it is expected to:

- Significantly improve, develop or restore physical functions you lost as a result of an acute 

illness, injury or surgical procedure, or

- Relearn skills so you can significantly improve your ability to perform activities of daily living 

on your own.

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- Speech therapy without regard to whether there is a physical cause.

Speech function is the ability to express thoughts, speak words and form sentences. Speech 

impairment is difficulty with expressing one’s thoughts with spoken words.

 Cognitive rehabilitation associated with physical rehabilitation, but only when:

- Your cognitive deficits are caused by neurologic impairment due to trauma, stroke, or 

encephalopathy and 

- The therapy is coordinated with us as part of a treatment plan intended to restore previous 

cognitive function.

Spinal manipulation

Eligible health services include spinal manipulation to correct a muscular or skeletal problem. 

Your provider must establish or approve a treatment plan that details the treatment, and specifies 

frequency and duration.

Habilitation therapy services 

Habilitation therapy services are services that help you keep, learn, or improve skills and functioning for 

daily living (e.g. therapy for a child who isn’t walking or talking at the expected age)

Eligible health services include habilitation therapy services your physician prescribes. The services have 

to be performed by:

 A licensed or certified physical, occupational or speech therapist 

 A hospital, skilled nursing facility, or hospice facility

 A home health care agency

 A physician

Habilitation therapy services have to follow a specific treatment plan, ordered by your physician.

Outpatient physical, occupational, and speech therapy 

Eligible health services include: 

 Physical therapy, if it is expected to develop any impaired function

 Occupational therapy (except for vocational rehabilitation or employment counseling), if it is 

expected to:

- Develop any impaired function, or

- Relearn skills so you can significantly develop your ability to perform activities of daily living 

on your own.

 Speech therapy is covered without regard to whether there is a physical cause.

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7. Other services

Acupuncture

Eligible health services include the treatment by the use of acupuncture (manual or 

electroacupuncture) provided by your physician, if the service is performed:

• As a form of anesthesia in connection with a covered surgical procedure and 

• To alleviate chronic pain or to treat:

- Postoperative and chemotherapy-induced nausea and vomiting

- Nausea of pregnancy

- Postoperative dental pain

- Temporomandibular disorders (TMD)

- Migraine headache

- Pain from osteoarthritis of the knee or hip (adjunctive therapy)

Ambulance service 

Eligible health services include transport by professional ground ambulance services:

 To the first hospital to provide emergency services.

 From one hospital to another hospital if the first hospital cannot provide the emergency 

services you need.

 From hospital to your home or to another facility if an ambulance is the only safe way to 

transport you.

 From your home to a hospital if an ambulance is the only safe way to transport you. Transport is 

limited to 100 miles.

Your plan also covers transportation to a hospital by professional air or water ambulance when:

 Professional ground ambulance transportation is not available.

 Your condition is unstable, and requires medical supervision and rapid transport.

 You are travelling from one hospital to another and

- The first hospital cannot provide the emergency medical services you need, and 

- The two conditions above are met.

Clinical trial therapies (experimental or investigational) 

Eligible health services include experimental or investigational drugs, devices, treatments or 

procedures from a provider under an “approved clinical trial” only when you have cancer or terminal 

illnesses and all of the following conditions are met:

 Standard therapies have not been effective or are not appropriate.

 We determine based on published, peer-reviewed scientific evidence that you may benefit from 

the treatment.

An "approved clinical trial" is a clinical trial that meets all of these criteria:

 The FDA has approved the drug, device, treatment, or procedure to be investigated or has 

granted it investigational new drug (IND) or group c/treatment IND status. This requirement 

does not apply to procedures and treatments that do not require FDA approval.

 The clinical trial has been approved by an Institutional Review Board that will oversee the 

investigation. 

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 The clinical trial is sponsored by the National Cancer Institute (NCI) or similar federal 

organization.

 The trial conforms to standards of the NCI or other, applicable federal organization.

 The clinical trial takes place at an NCI-designated cancer center or takes place at more than one 

institution.

 You are treated in accordance with the protocols of that study.

Clinical trials (routine patient costs)

Eligible health services include "routine patient costs" incurred to you by a provider in connection with 

participation in an "approved clinical trial" as a “qualified individual" for cancer or other life-threatening 

disease or condition, as those terms are defined in the federal Public Health Service Act, Section 2709. 

An approved clinical trial must satisfy one of the following:

 Federally funded trials:

- The study or investigation is approved or funded by one or more of the following:

o The National Institutes of Health

o The Centers for Disease Control and Prevention

o The Agency for Health Care Research and Quality

o The Centers for Medicare & Medicaid Services

o Cooperative group or center of any of the entities described above or the Department 

of Defense or the Department of Veterans Affairs

o A qualified non-governmental research entity identified in the guidelines issued by the 

National Institutes of Health for center support grants

o The Department of Veterans Affairs

o The Department of Defense

o The Department of Energy

- For those approved by the Departments of Veterans Affairs, Defense or Energy, the study or 

investigation must have been reviewed and approved through a system of peer review that 

the federal Secretary of Health and Human Services determines:

o To be comparable to the system of peer review of studies and investigations used by 

the National Institutes of Health

o Assures unbiased review of the highest scientific standards by qualified individuals who 

have no interest in the outcome of the review.

 The study or investigation is conducted under an investigational new drug application reviewed 

by the Food and Drug Administration

 The study or investigation is a drug trial that is exempt from having such an investigational new 

drug application

Durable medical equipment (DME)

Eligible health services include the expense of renting or buying DME and accessories you need to 

operate the item from a DME supplier. Your plan will cover either buying or renting the item, depending 

on which we think is more cost efficient. If you purchase DME, that purchase is only eligible for coverage 

if you need it for long-term use.

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Coverage includes:

 One item of DME for the same or similar purpose.

 Repairing DME due to normal wear and tear. It does not cover repairs needed because of 

misuse or abuse.

 A new DME item you need because your physical condition has changed. It also covers buying a 

new DME item to replace one that was damaged due to normal wear and tear, if it would be 

cheaper than repairing it or renting a similar item.

Your plan only covers the same type of DME that Medicare covers. But there are some DME items 

Medicare covers that your plan does not. We list examples of those in the exceptions section.

Nutritional supplements 

Eligible health services include formula and low protein modified food products ordered by a physician

for the treatment of phenylketonuria or an inherited disease of amino and organic acids. 

For purposes of this benefit, “low protein modified food product” means foods that are specifically 

formulated to have less than one gram of protein per serving and are intended to be used under the 

direction of a physician for the dietary treatment of phenylketonuria or any inherited metabolic 

disease. Low protein modified food products do not include foods that are naturally low in protein.

Obesity (bariatric) surgery

Eligible health services include obesity surgery, which is also known as “weight loss surgery.” Obesity 

surgery is a type of procedure performed on people who are morbidly obese, for the purpose of losing 

weight. 

Obesity is typically diagnosed based on your body mass index (BMI). To determine whether you qualify 

for obesity surgery, your doctor will consider your BMI and any other condition or conditions you may 

have. In general, obesity surgery will not be approved for any member with a BMI less than 35. 

Your doctor will request approval from us in advance of your obesity surgery. We will cover charges 

made by a network provider for the following outpatient weight management services: 

 An initial medical history and physical exam

 Diagnostic tests given or ordered during the first exam

 Outpatient prescription drug benefits included under the Outpatient prescription drugs section

Health care services include one bariatric surgical procedure. However, eligible health services also 

include a multi-stage procedure when planned and approved by us. Your health care services include 

adjustments after an approved lap band procedure. This includes approved adjustments in an office or 

outpatient setting.

You may go to any of our network facilities that perform obesity surgeries. 

Orthotic devices

Eligible health services include mechanical supportive devices ordered by your physician for the 

treatment of weak or muscle deficient feet.

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Eligible health services also include special footwear if you suffer from a foot disfigurement caused by: 

 Cerebral palsy

 Arthritis

 Polio

 Spinabifida

 Diabetes

 Accidental or developmental disability.

Osteoporosis

Eligible health services include the diagnosis, treatment and management of osteoporosis by a 

physician. The services include Food and Drug Administration approved technologies, including bone 

mass measurement.

Prosthetic devices

Eligible health services include the initial provision and subsequent replacement of a prosthetic device 

that your physician orders and administers. But we cover it only if we approve the device in advance.

Prosthetic device means:

 A device that temporarily or permanently replaces all or part of an external body part lost or 

impaired as a result of illness or injury or congenital defects. 

Coverage includes:

 Repairing or replacing the original device you outgrow or that is no longer appropriate because 

your physical condition changed

 Replacements required by ordinary wear and tear or damage

 Instruction and other services (such as attachment or insertion) so you can properly use the 

device

Spinal manipulation

Eligible health services include spinal manipulation to correct a muscular or skeletal problem, but only if 

your provider establishes or approves a treatment plan that details the treatment, and specifies 

frequency and duration. 

Vision care 

Pediatric vision care 

Routine vision exams

Eligible health services include a routine vision exam provided by an ophthalmologist or optometrist. 

The exam will include refraction and glaucoma testing.

Adult vision care

Routine vision exams

Eligible health services include a routine vision exam provided by an ophthalmologist or optometrist. 

The exam will include refraction and glaucoma testing.

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What your plan doesn’t cover – some eligible health service 

exceptions

We already told you about the many health care services and supplies that are eligible for coverage 

under your plan in the Eligible health services under your plan section. And we told you there, that some 

of those health care services and supplies have exceptions (exclusions). For example, physician care is 

an eligible health service but physician care for cosmetic surgery is never covered. This is an exception 

(exclusion).

In this section we tell you about the exceptions. We've grouped them to make it easier for you to find 

what you want.

 Under "General exceptions" we've explained what general services and supplies are not 

covered under the entire plan.

 Below the general exceptions, in “Exceptions under specific types of care,” we've 

explained what services and supplies are exceptions under specific types of care or 

conditions.

Please look under both categories to make sure you understand what exceptions may apply in your 

situation. 

And just a reminder, you'll find coverage limitations in the schedule of benefits.

General exceptions

Blood, blood plasma, synthetic blood, blood derivatives or substitutes

Examples of these are:

 The provision of blood to the hospital, other than blood derived clotting factors

 Any related services including processing, storage or replacement expenses

 The services of blood donors, apheresis or plasmapheresis 

For autologous blood donations, only administration and processing expenses are covered. 

Cosmetic services and plastic surgery

 Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or 

enhance the shape or appearance of the body. Whether or not for psychological or 

emotional reasons.

Counseling

 Religious, career, or financial counseling.

Court-ordered services and supplies

 Includes those court-ordered services and supplies, or those required as a condition of parole, 

probation, release or as a result of any legal proceeding

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Custodial care

Examples are:

 Routine patient care such as changing dressings, periodic turning and positioning in bed.

 Administering oral medications.

 Care of a stable tracheostomy (including intermittent suctioning).

 Care of a stable colostomy/ileostomy.

 Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings.

 Care of a bladder catheter (including emptying/changing containers and clamping tubing).

 Watching or protecting you.

 Respite care, adult (or child) day care, or convalescent care.

 Institutional care. This includes room and board for rest cures, adult day care and convalescent 

care.

 Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or 

preparing foods.

 Any other services that a person without medical or paramedical training could be trained to 

perform.

 Any service that can be performed by a person without any medical or paramedical training.

Dental care

 Dental services related to:

- The care, filling, removal or replacement of teeth and treatment of injuries to or diseases of 

the teeth

- Dental services related to the gums

- Apicoectomy (dental root resection)

- Orthodontics

- Root canal treatment

- Soft tissue impactions

- Alveolectomy

- Augmentation and vestibuloplasty treatment of periodontal disease

- False teeth

- Prosthetic restoration of dental implants

- Dental implants 

This exclusion does not include removal of bony impacted teeth, bone fractures, removal of tumors, and 

odontogenic cysts.

Educational services

Examples of those services are:

 Any service or supply for education, training or retraining services or testing. This 

includes special education, remedial education, job training and job hardening 

programs.

 Services eligible under the Individuals with Disabilities in Education Act (IDEA).

Examinations

Any health or dental examinations needed:

 Because a third party requires the exam. Examples are, examinations to get or keep a 

job, or examinations required under a labor agreement or other contract.

 Because a law requires it.

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 To buy insurance or to get or keep a license.

 To travel.

 To go to a school, camp, or sporting event, or to join in a sport or other recreational 

activity.

Experimental or investigational

 Experimental or investigational drugs, devices, treatments or procedures unless otherwise 

covered under Clinical trial therapies (experimental or investigational) or covered under Clinical 

trials (routine patient costs). See the Eligible health services under your plan – Other services

section. 

Facility charges

For care, services or supplies provided in:

 Rest homes

 Assisted living facilities

 Similar institutions serving as a persons’ main residence or providing mainly custodial or 

rest care

 Health resorts

 Spas or sanitariums

 Infirmaries at schools, colleges, or camps

Foot care

 Services and supplies for:

- The treatment of calluses, bunions, toenails, hammertoes, or fallen arches

- The treatment of weak feet, chronic foot pain or conditions caused by routine 

activities, such as walking, running, working or wearing shoes

- Supplies (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, 

ankle braces, guards, protectors, creams, ointments and other equipment, devices 

and supplies

Growth/Height care

 A treatment, device, drug, service or supply to increase or decrease height or alter the 

rate of growth

 Surgical procedures, devices and growth hormones to stimulate growth except as 

needed for gender reassignment. See the Eligible health services under your planGender reassignment section

Hearing aids and exams

Medical supplies – outpatient disposable

 Any outpatient disposable supply or device. Examples of these are:

- Sheaths

- Bags

- Elastic garments

- Support hose

- Bandages

- Bedpans

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- Syringes

- Blood or urine testing supplies

- Other home test kits

- Splints

- Neck braces

- Compresses

- Other devices not intended for reuse by another patient

Other primary payer

 Payment for a portion of the charge that Medicare or another party is responsible for as 

the primary payer.

Outpatient prescription or non-prescription drugs and medicines

 Outpatient prescription or non-prescription drugs and medicines provided by your 

employer or through a third party vendor contract with your employer.

 Drugs that are included on the list of specialty prescription drug as covered under your 

outpatient prescription drug plan.

Personal care, comfort or convenience items

 Any service or supply primarily for your convenience and personal comfort or that of a 

third party.

Services provided by a family member

 Services provided by a spouse, domestic partner, parent, child, stepchild, brother, 

sister, in-law or any household member.

Services, supplies and drugs received outside of the United States

 Non-emergency medical services, outpatient prescription drugs or supplies received outside of 

the United States. They are not covered even if they are covered in the United States under this 

EOC.

Sexual dysfunction and enhancement

 Any treatment, prescription drug, service, or supply to treat sexual dysfunction, 

enhance sexual performance or increase sexual desire, including:

- Surgery, prescription drugs, implants, devices or preparations to correct or enhance 

erectile function, enhance sensitivity, or alter the shape or appearance of a sex 

organ

- Sex therapy, sex counseling, marriage counseling, or other counseling or advisory 

services

Strength and performance

 Services, devices and supplies such as drugs or preparations designed primarily for the purpose 

of enhancing your strength, physical condition, endurance, or physical performance.

Telemedicine 

 Any services that are given by providers that are not contracted with Aetna as 

telemedicine providers. Any services that are not provided during an internet-based 

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consult or via telephone.

Treatment in a federal, state, or governmental entity

 Any care in a hospital or other facility owned or operated by any federal, state or other 

governmental entity, except to the extent coverage is required by applicable laws

Therapies and tests

 Full body CT scans

 Hair analysis

 Hypnosis and hypnotherapy

 Massage therapy, except when used as a physical therapy modality

 Sensory or auditory integration therapy

Tobacco cessation

 Any treatment, drug, service or supply to stop or reduce smoking or the use of other 

tobacco products or to treat or reduce nicotine addiction, dependence or cravings, 

including, medications, nicotine patches and gum unless recommended by the United 

States Preventive Services Task Force (USPSTF). This also includes:

- Counseling, except as specifically provided in the Eligible health services under your 

plan – Preventive care and wellness section

- Hypnosis and other therapies

- Medications, except as specifically provided in the Eligible health services under your 

plan – Outpatient prescription drugs section

- Nicotine patches

- Gum

Vision care

 Vision care services and supplies, including:

- Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not 

properly coordinated for binocular vision) and

- Laser in-situ keratomileusis (LASIK), including related procedures designed to surgically 

correct refractive errors

Wilderness Treatment Programs

• Wilderness treatment programs (whether or not the program is part of a residential 

treatment facility or otherwise licensed institution).

Work related illness or injuries

 Coverage available to you under worker’s compensation or under a similar program under 

local, state or federal law for any illness or injury related to employment or self-employment. 

 A source of coverage or reimbursement will be considered available to you even if you waived 

your right to payment from that source. You may also be covered under a workers’ 

compensation law or similar law. If you submit proof that you are not covered for a particular 

illness or injury under such law, then that illness or injury will be considered “non-occupational” 

regardless of cause.

 The eligible health services under this plan are not designed to duplicate any benefit to which 

you are entitled under workers’ compensation law. All sums payable for workers’ compensation 

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services provided under this plan shall be payable to, and retained by us. You shall complete 

and submit to us such consents, releases, assignments and other documents reasonably 

requested by us in order to obtain or assure reimbursement under the worker's compensation 

law.

Additional exceptions for specific types of care

1. Preventive care and wellness

 Services for diagnosis or treatment of a suspected or identified illness or injury

 Exams given during your stay for medical care

 Services not given by a physician or under his or her direction

 Psychiatric, psychological, personality or emotional testing or exams

2. Physicians and other health professionals

There are no additional exceptions specific to physicians and other health professionals.

3. Hospital and other facility care

Alternatives to facility stays

Outpatient surgery and physician surgical services

 The services of any other physician who helps the operating physician

 A stay in a hospital (hospital stays are covered in the Eligible health services under your plan –

Hospital and other facility care section)

 A separate facility charge for surgery performed in a physician’s office

 Services of another physician for the administration of a local anesthetic

Home health care

 Services for infusion therapy

 Services provided outside of the home (such as in conjunction with school, vacation, work or 

recreational activities)

 Transportation

 Services or supplies provided to a minor or dependent adult when a family member or caregiver 

is not present

Hospice care

 Funeral arrangements

 Pastoral counseling

 Financial or legal counseling. This includes estate planning and the drafting of a will

 Homemaker or caretaker services. These are services which are not solely related to your care 

and may include:

- Sitter or companion services for either you or other family members 

- Transportation

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- Maintenance of the house

Private duty nursing (See home health care in the Eligible health services under your plan

section regarding coverage of nursing services).

4. Emergency services and urgent care

 Non-emergency care in a hospital emergency room facility

 Non-urgent care in an urgent care facility (at a non-hospital freestanding facility)

5. Specific conditions

Artificial organs

 Any device that would perform the function of a body organ.

Family planning services - other

 Voluntary sterilization for males 

 Voluntary termination of pregnancy

 Reversal of voluntary sterilization procedures, including related follow-up care

 Family planning services received while confined as an inpatient in a hospital or other facility

Maternity and related prenatal care

 Any services and supplies related to births that take place in the home or in any other 

place not licensed to perform deliveries.

Mental health treatment

 Mental health services for the following categories (or equivalent terms as listed in the most 

recent version of the International Classification of Diseases (ICD)): 

- Dementias and amnesias without behavioral disturbances

- Sexual deviations and disorders except for gender identity disorders

- Tobacco use disorders

- Specific disorders of sleep

- Antisocial or dissocial personality disorder

- Pathological gambling, kleptomania, pyromania

- Specific delays in development (learning disorders, academic underachievement) 

- Intellectual disability

- Wilderness Treatment Program or any such related or similar program

- School and/or education service.

Substance related disorders treatment

• Except as provided in the Eligible health services under your plan – Substance related disorders 

treatment section alcoholism or drug abuse rehabilitation treatment on an inpatient or 

outpatient basis

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Transplant services

 Services and supplies furnished to a donor when the recipient is not a covered person

 Harvesting and storage of organs, without intending to use them for immediate 

transplantation for your existing illness

 Harvesting and/or storage of bone marrow, or hematopoietic stem cells without 

intending to use them for transplantation within 12 months from harvesting, for an 

existing illness

Treatment of infertility

 Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH 

agonists.

• All charges associated with:

- Surrogacy for you or the surrogate. A surrogate is a female carrying her own genetically 

related child where the child is conceived with the intention of turning the child over to be 

raised by others, including the biological father.

- Cryopreservation of eggs, embryos, or sperm. 

- Storage of eggs, embryos, or sperm.

- Thawing of cryopreserved eggs, embryos or sperm. 

- The care of the donor in a donor egg cycle. This includes, but is not limited to, any payments 

to the donor, donor screening fees, fees for lab tests, and any charges associated with care 

of the donor required for donor egg retrievals or transfers.

- The use of a gestational carrier for the female acting as the gestational carrier. A gestational 

carrier is a female carrying an embryo to which she is not genetically related.

- Obtaining sperm for ART services.

• Home ovulation prediction kits or home pregnancy tests.

• The purchase of donor embryos, donor oocytes, or donor sperm. 

• Reversal of voluntary sterilizations, including follow-up care.

 Ovulation induction with menotropins, intrauterine insemination and any related services, 

products or procedures.

 In vitro fertilization (IVF), Zygote intrafallopian transfer (ZIFT), Gamete intrafallopian 

transfer (GIFT), Cryopreserved embryo transfers and any related services, products or 

procedures (such as Intracytoplasmic sperm injection (ICSI) or ovum microsurgery).

6. Specific therapies and tests

Acupuncture and acupuncture therapy

Outpatient infusion therapy

 Specialty prescription drugs and medicines provided by your employer or through a 

third party vendor contract with your employer.

 Drugs that are included on the list of specialty prescription drugs as covered under your 

outpatient prescription drug plan.

 Enteral nutrition

 Blood transfusions and blood products, but not the administration of the blood or blood 

products

 Dialysis

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Short-term rehabilitation services

Outpatient cognitive rehabilitation, physical, and occupational therapy

 Except for physical therapy or occupational therapy provided for the treatment of Autism 

Spectrum Disorder, therapies to treat delays in development and/or chronic conditions. 

Examples of non-covered diagnoses that are considered both developmental and/or chronic in 

nature are:

- Down syndrome

- Cerebral palsy 

 Any service unless provided in accordance with a specific treatment plan

 Services you get from a home health care agency.

 Services provided by a physician, or treatment covered as part of the spinal manipulation 

benefit. This applies whether or not benefits have been paid under the spinal manipulation 

section.

 Services not given by a physician (or under the direct supervision of a physician), physical,

occupational or speech therapist.

 Services for the treatment of delays in development unless as a result of a gross anatomical 

defect present at birth.

Habilitation therapy services

Physical and occupational therapy

 Except for physical therapy or occupational therapy provided for the treatment of Autism 

Spectrum Disorder, therapies to treat delays in development and/or chronic conditions. An 

example of a non-covered diagnosis that is considered both developmental and/or chronic in 

nature is:

- Down syndrome

 Any service unless provided in accordance with a specific treatment plan

 Services you get from a home health care agency.

 Services not given by a physician (or under the direct supervision of a physician), physical,

occupational or speech therapist.

 Services for the treatment of delays in development unless as a result of a gross anatomical 

defect present at birth.

7. Other services

Ambulance services

 Fixed wing air ambulance from an out-of-network provider

Clinical trial therapies (experimental or investigational)

 Your plan does not cover clinical trial therapies (experimental or investigational), except as 

described in the Eligible health services under your plan - Clinical trial therapies (experimental or 

investigational) section.

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Clinical trial therapies (routine patient costs)

 Services and supplies related to data collection and record-keeping that is solely needed due to 

the clinical trial (i.e. protocol-induced costs)

• Services and supplies provided by the trial sponsor without charge to you

• The experimental intervention itself (except medically necessary Category B investigational 

devices and promising experimental and investigational interventions for terminal illnesses in 

certain clinical trials in accordance with Aetna’s claim policies).

Durable medical equipment (DME)

Examples of these are:

 Whirlpools

 Portable whirlpool pumps

 Sauna baths

 Message devices

 Over bed tables

 Elevators

 Communication aids

 Vision aids

 Telephone alert systems

Nutritional supplements

 Any food item, including infant formulas, nutritional supplements, vitamins, plus prescription

vitamins, medical foods and other nutritional items, even if it is the sole source of nutrition, 

except as covered in the Eligible health services under your plan – Other services section

Prosthetic devices

 Services covered under any other benefit

 Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet, unless 

required for the treatment of or to prevent complications of diabetes, or if the orthopedic shoe 

is an integral part of a covered leg brace

 Trusses, corsets, and other support items

 Repair and replacement due to loss, misuse, abuse or theft

Spinal manipulation

 Care in connection with the detection and correction by manual or mechanical means of 

structural imbalance, distortion or dislocation in the human body.

 Other physical treatment of any condition caused by or related to neuromusculoskeletal 

disorders of the spine, including manipulation of the spine.

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Who provides the care

Just as the starting point for coverage under your plan is whether the services and supplies are eligible 

health services, the foundation for getting covered care is the network. This section tells you about 

network providers. 

Network providers

We have contracted with providers in the service area to provide eligible health services to you. These 

providers make up the network for your plan. For you to receive the network level of benefits, you 

must use network providers for eligible health services. There are three exceptions:

 Emergency services – refer to the description of emergency services and urgent care in the 

Eligible health services under your plan section. 

 Urgent care – refer to the description of emergency services and urgent care in the Eligible 

health services under your plan section.

 Network provider not reasonably available – You can get eligible health services under your 

plan that are provided by an out-of-network provider if an appropriate network provider is not 

reasonably available. You must request access to the out-of-network provider in advance and 

we must agree. Contact Member Services at the toll-free number on your ID card for assistance.

You may select a network provider from the directory through your secure member website at 

www.aetna.com. You can search our online directory, DocFind®, for names and locations of providers. 

You will not have to submit claims for treatment received from network providers. Your network 

provider will take care of that for you. And we will directly pay the network provider for what the plan 

owes.

Your PCP

For you to receive the network level of benefits eligible health services must be accessed through your 

PCP’s office. They will provide you with primary care. 

A PCP can be any of the following providers available under your plan:

 General practitioner

 Family physician

 Internist

 Pediatrician

 OB, GYN, and OB/GYN

How do you choose your PCP?

You can choose a PCP from the list of PCPs in our directory. See the Who provides the care, Network

providers section. 

Each covered family member is required to select their own PCP. You may each select your own PCP. 

You must select a PCP for your covered dependent if they are a minor or cannot choose a PCP on their 

own.

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What will your PCP do for you?

Your PCP will coordinate your medical care or may provide treatment. They may send you to other 

network providers.

Your PCP can also:

 Order lab tests and radiological services.

 Prescribe medicine or therapy.

 Arrange a hospital stay or a stay in another facility.

Your PCP may be affiliated with other medical groups (i.e. integrated delivery systems, independent 

practice associations (IPAs) and physician-hospital organizations). If you select a PCP with these 

affiliations, you will probably be referred to specialists and hospitals within that medical group. 

Your PCP will give you a written or electronic referral to see other network providers. 

How do I change my PCP?

You may change your PCP at any time. You can call us at the toll-free number on your ID card or log on 

to your secure member website at www. aetna.com to make a change. 

What happens if I do not select a PCP?

Because having a PCP is so important, we may choose one for you. You will get an ID card in the mail. 

We will tell you the name, address and telephone number of your PCP.

Your eligible health services will be limited to care provided by direct access network providers, 

emergency services and urgent care services. 

How is my PCP paid?

Your PCP and other providers may be paid in any of the following ways, depending on their contract 

with us: 

 A fixed price per service

 A fixed price per day

 A fee for each service set by a fee schedule

 A fixed monthly amount per member

Providers who contract with us have no requirement to comply with:

 Specified numbers

 Targeted averages

 Maximum duration for patient visits

We design our compensation arrangements to encourage our providers to provide the most 

appropriate care and to discourage unnecessary and potentially detrimental care.

When providers are paid a fixed monthly amount per member, we incorporate specific “quality factors” 

into the compensation process. These quality factors include:

 Appropriate diagnostic testing

 Specialty and hospital utilization

 Member satisfaction survey results

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 Thoroughness of medical chart documentation

 Clinical care measures for diabetes, asthma and other conditions

 Number of scheduled office hours

 Range of office procedures offered

 Around the clock coverage

 Participation in continuing education programs

We encourage you to ask your PCP and other providers how they are paid, including if their contracts 

include any financial incentives. 

Keeping a provider you go to now (continuity of care) 

You may have to find a new provider when:

 You join the plan and the provider you have now is not in the network.

 You are already a member of Aetna and your provider stops being in our network. 

However, in some cases, you may be able to keep going to your current provider to complete a 

treatment or to have treatment that was already scheduled. This is called continuity of care.

If you are a new enrollee When your provider stops 

participation with Aetna

Request for approval You need to complete a 

Transition Coverage Request 

form and send it to us. You can 

get this form by calling the toll 

free number on your ID card. 

You or your provider should call 

Aetna for approval to continue 

any care.

Length of transitional period Care will continue during a 

transitional period, usually 90 

days, but this may vary based 

on your condition. 

Care will continue during a 

transitional period, usually 90 

days, but this may vary based 

on your condition. This date is 

based on the date the provider 

terminated their participation 

with Aetna.

If you are pregnant, the transitional period will include the time through postpartum care directly 

related to the delivery.

If you are receiving mental health treatment, care will continue during a transitional period of one year.

We will authorize coverage for the transitional period only if the provider agrees to our usual terms and 

conditions for contracting providers.

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What the plan pays and what you pay

Who pays for your eligible health services – this plan, both of us, or just you? That depends. This section 

gives the general rule and explains these key terms:

 Your copayments/coinsurance

 Your maximum out-of-pocket limit

We also remind you that sometimes you will be responsible for paying the entire bill: for example, if you 

get care that is not an eligible health service.

The general rule

When you get eligible health services:

 You pay for the entire expense up to any deductible limit.

And then 

 The plan and you share the expense up to any maximum out-of-pocket limit. The schedule of 

benefits lists how much your plan pays and how much you pay for each type of health care 

service. Your share is called a copayment/coinsurance.

And then

 The plan pays the entire expense after you reach your maximum out-of-pocket limit.

Important exception – when your plan pays all

Your plan pays the entire expense for all eligible health services under the preventive care and wellness 

benefit.

 When your plan requires precertification, your physician requested it, we refused it, and you 

get an eligible health service without precertification. See the Medical necessity, referral and 

precertification requirements section.

 Usually, when you get an eligible health service from someone who is not a network provider. 

See the Who provides the care section.

In all these cases, the provider may require you to pay the entire charge. And any amount you pay will 

not count towards your deductible or towards your maximum out-of-pocket limit. 

Special financial responsibility

You are responsible for the entire expense of:

 Cancelled or missed appointments

Neither you nor we are responsible for:

 Charges for which you have no legal obligation to pay

 Charges that would not be made if you did not have coverage

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 Charges, expenses, or cost is in excess of the negotiated charge

Where your schedule of benefits fits in

How your copayment/coinsurance works

Your copayment/coinsurance is the amount you pay for eligible health services. Your schedule of 

benefits shows you which copayments/coinsurance you need to pay for specific eligible health services. 

You will pay the PCP copayment/coinsurance when you select a PCP and get eligible health services

from them. You will pay the specialist copayment/coinsurance when you get eligible health services

from a network PCP that is not your PCP. If you did not select a PCP you will pay the specialist 

copayment/coinsurance for eligible health services from any network PCP or network specialist.

How your maximum out-of-pocket limit works

You will pay your deductible and copayments/coinsurance up to the maximum out-of-pocket limit for 

your plan. Your schedule of benefits shows the maximum out-of-pocket limits that apply to your plan. 

Once you reach your maximum out-of-pocket limit, your plan will pay for covered benefits for the 

remainder of that calendar year.

Important note:

See the schedule of benefits for any deductibles, copayments/coinsurance, maximum out-of-pocket 

limit and maximum age, visits, days, hours, admissions that may apply.

When you disagree - claim decisions and appeals procedures

In the previous section, we explained how you and we share responsibility for paying for your eligible 

health services. 

When a claim comes in, we decide and tell you how you and we will split the expense. We also explain 

what you can do if you think we got it wrong.

The California Department of Managed Health Care is responsible for regulating health care service 

plans. When you disagree with us, you should first follow our claims and appeals process before 

contacting the Department. Following our processes does not prohibit any potential legal rights or 

remedies that may be available to you. 

You can call the Department for help with a complaint or appeal involving: 

 An emergency

 One that has not been satisfactorily resolved us

 One that has remained unsolved for more than 30 days

You may also be eligible for an Independent Medical Review (IMR) as explained below. The IMR process 

will provide an impartial review of medical decisions made by us. 

The Department has a toll-free telephone number 1-888-HMO-2219 and a TDD line 1-877-688-9891 for 

the hearing and speech impaired. The Department’s Internet Web site (http://www.hmohelp.ca.gov) 

has complaint forms, IMR application forms and instructions. 

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Types of claims and communicating our claim decisions

Your network provider will send us a claim on your behalf. And we will review that claim for payment to 

the provider. 

There are different types of claims. The amount of time that we have to tell you about our decision on a 

claim depends on the type of claim. The section below will tell you about the different types of claims.

Urgent care claim

An urgent claim is one for which delay in getting medical care could put your life or health at risk. Or a 

delay might put your ability to regain maximum function at risk. Or it could be a situation in which you 

need care to avoid severe pain. 

If you are pregnant, an urgent claim also includes a situation that can cause serious risk to the health of 

your unborn baby.

Pre-service claim 

A pre-service claim is a claim that involves services you have not yet received and which we will pay for 

only if we precertify them. 

Post-service claim 

A post service claim is a claim that involves health care services you have already received. 

Concurrent care claim extension

A concurrent care claim extension occurs when you ask us to approve more services than we already 

have approved. Examples are extending a hospital stay or adding a number of visits to a provider. 

Concurrent care claim reduction or termination

A concurrent care claim reduction or termination occurs when we decide to reduce or stop payment for 

an already approved course of treatment. We will notify you of such a determination. You will have 

enough time to file an appeal. Your coverage for the service or supply will continue until you receive a

final appeal decision from us or an external review organization if the situation is eligible for external 

review.

During this continuation period, you are still responsible for your share of the costs, such as 

copayments/coinsurance and deductibles that apply to the service or supply. If we uphold our decision 

at the final internal appeal, you will be responsible for all of the expenses for the service or supply 

received during the continuation period.

The chart below shows a timetable view of the different types of claims and how much time we have to 

tell you about our decision. 

We may need to tell your physician about our decision on some types of claims, such as a concurrent 

care claim, or a claim when you are already receiving the health care services or are in the hospital.

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Type of notice Urgent care 

claim

Pre-service 

claim

Post-service 

claim

Concurrent care 

claim

Initial determination (us) 72 hours 15 days 30 days 24 hours for 

urgent request*

15 calendar days 

for non-urgent 

request

Extensions None 15 days 15 days Not applicable

Additional information 

request (us)

72 hours 15 days 30 days Not applicable

Response to additional 

information request (you)

48 hours 45 days 45 days Not applicable

*We have to receive the request at least 24 hours before the previously approved health care services 

end. 

Adverse benefit determinations

We pay many claims at the full rate negotiated with a network provider, except for your share of the 

costs. But sometimes we pay only some of the claim. And sometimes we deny payment entirely. Any 

time we deny even part of the claim that is an “adverse benefit determination” or “adverse decision”. It 

is also an “adverse benefit determination” if we rescind your coverage entirely.

If we make an adverse benefit determination, we will tell you in writing.

The difference between a complaint and an appeal

A Complaint

You may not be happy about a network provider or an operational issue, and you may want to 

complain. You can call the toll-free number on your ID card, or write Member Services. Your complaint 

should include a description of the issue. You should include copies of any records or documents that 

you think are important. We will review the information and provide you with a written response within 

30 calendar days of receiving the complaint. We will let you know if we need more information to make 

a decision.

An Appeal

You can ask us to re-review an adverse benefit determination. This is called an appeal. You can appeal to 

us by calling the toll-free number on your ID card.

Appeals of adverse benefit determinations

You can appeal our adverse benefit determination. We will assign your appeal to someone who was not 

involved in making the original decision. You must file an appeal within 180 calendar days from the time 

you receive the notice of an adverse benefit determination.

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You can appeal by sending a written appeal to the address on the notice of adverse benefit 

determination, by calling the toll-free number on your ID card.

You need to include:

 Your name

 Your employer’s name

 A copy of the adverse benefit determination 

 Your reasons for making the appeal

 Any other information you would like us to consider

Another person may submit an appeal for you, including a provider. That person is called an authorized 

representative. You need to tell us if you choose to have someone else appeal for you (even if it is your 

provider). You should fill out an authorized representative form telling us that you are allowing 

someone to appeal for you. You can get this form on our website or by calling the toll-free number on 

your ID card. You can use an authorized representative at any level of appeal.

You can appeal two times under this plan. If you appeal a second time you must present your appeal 

within 60 calendar days from the date you receive the notice of the first appeal decision. 

Urgent care or pre-service claim appeals

If your claim is an urgent claim or a pre-service claim, your provider may appeal for you without having 

to fill out a form.

We will provide you with any new or additional information that we used or that was developed by us to 

review your claim. We will provide this information at no cost to you before we give you a decision at 

your last available level of appeal. This decision is called the final adverse benefit determination. You can 

respond to this information before we tell you what our final decision is. 

Timeframes for deciding appeals

The amount of time that we have to tell you about our decision on an appeal claim depends on the type 

of claim. The chart below shows a timetable view of the different types of claims and how much time we 

have to tell you about our decision. 

Type of notice Urgent care 

claim

Pre-service 

claim

Post-service 

claim

Concurrent care 

claim

Appeal determinations at 

each level (us)

36 hours 15 days 30 days As appropriate to 

type of claim

Extensions None None None

Exhaustion of appeals process

In most situations you must complete the two levels of appeal with us before you can take these other 

actions:

 Contact the California Department of Managed Health Care to request an investigation of a 

complaint or appeal. File a complaint or appeal with the California Department of Managed 

Health Care. 

 Appeal through an external review process.

 Pursue arbitration, litigation or other type of administrative proceeding.

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But sometimes you do not have to complete the two levels of appeals process before you may take 

other actions. These situations are:

 You have an urgent claim or a claim that involves ongoing treatment. You can have your claim 

reviewed internally and at the same time through the independent medical review process.

 We did not follow all of the claim determination and appeal requirements of the Federal 

Department of Health and Human Services. But, you will not be able to proceed directly to 

external review if:

- The rule violation was minor and not likely to influence a decision or harm you.

- The violation was for a good cause or beyond our control.

- The violation was part of an ongoing, good faith exchange between you and us.

Independent medical review

Independent medical review is a review managed by the California Department of Managed Health 

Care. 

You have a right to an independent medical review if:

 We decided the service or supply is not medically necessary or not appropriate (disputed health 

care service). 

 We decided the service or supply is experimental or investigational.

If our claim decision is one for which you can seek independent medical review, we will say that in the 

notice of adverse benefit determination or final adverse benefit determination we send you. That notice 

also will include the independent medical review application form. You should complete the form and 

send it (in the envelope provided) to the California Department of Managed Health Care. The 

Department will review your request and determine if you are eligible for independent medical review.

When we receive notice from the Department approving your request for an independent medical 

review, we will submit the documents required to the Department, you and your provider.

Your appeal will be submitted to the Independent Medical Review Organization (IMRO) for review by a 

medical specialist or a panel of medical specialists. Those specialists will determine whether or not the 

care is medically necessary. You will receive a copy of the independent medical review assessment.

The independent medical review will not cost you any money.

Independent medical review procedure for disputed health care services

You must:

 File an appeal regarding the disputed health care services

 Have participated in our appeals process for 30 days

 Received our final appeal decision

If your appeal involves an expedited complaint or appeal, you are not required to participate in our 

appeals process for more than three days. 

Your provider must have recommended the services or you must have received urgent or emergency 

care that a provider deemed medically necessary. Or, you must have been seen by a provider for the 

diagnosis or treatment of the medical condition. Upon request, we will expedite access to a network 

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provider. You may request an independent medical review whether or not the provider recommends 

the service.

You may also request an independent medical review for services recommended or performed by an 

out-of-network provider. We have no liability to pay for the services of an out-of-network provider 

unless you have been referred according to the referral requirements. See the Medical necessity, 

referral and precertification requirements section for more details. 

Independent medical review procedure for experimental and investigative treatment

You can request an independent medical review when:

 You have a life-threatening or seriously debilitating illness

 Your physician certifies that you have that condition and:

- Standard therapies have not been effective in improving your condition

- Standard therapies would not be medically appropriate

- There is no more beneficial standard therapy covered by the plan than what your 

physician is proposing 

- Your physician has certified in writing that the proposed treatment is more beneficial to 

you than any other standard therapy

- You or your physician has provided us with a written statement that certifies the 

requested treatment is more beneficial to you than any other standard therapy. You or 

your physician must base this statement on two forms of medical and scientific 

evidence. 

The chart below shows a timetable view of the independent medical review timeline.

Type of treatment When we notify 

you

When we send info to the 

DMHC

When the IMRO decides

Experimental and 

investigative

5 days 3 days after receiving notice 

they approved your request

24 hours for urgent request

30 days

3 days for urgent request

Disputed healthcare 

services

At the end of 

the appeals 

process

3 days after receiving notice 

they approved your request

24 hours for urgent request

30 days

3 days for urgent request

What happens after the IMRO makes their decision?

If the IMRO determines that the care requested is medically necessary, or does not qualify as 

experimental or investigational, we will cover the services which were the subject of the appeal. 

There are two scenarios when you may be able to get a faster external review:

For initial adverse determinations

Your provider tells us that a delay in your receiving health care services would:

 Jeopardize your life, health or ability to regain maximum function, or 

 Be much less effective if not started right away (in the case of experimental or investigational

treatment)

For final adverse determinations

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Your provider tells us that a delay in your receiving health care services would:

 Jeopardize your life, health or ability to regain maximum function 

 Be much less effective if not started right away (in the case of experimental or investigational

treatment), or

 The final adverse determination concerns an admission, availability of care, continued stay or 

health care service for which you received emergency services, but have not been discharged 

from a facility

If your situation qualifies for this faster review, you will receive a decision within 72 hours of us getting 

your request.

Recordkeeping

We will keep the records of all complaints and appeals for at least 10 years. 

Fees and expenses

We do not pay any fees or expenses incurred by you in pursuing a complaint or appeal.

Binding arbitration 

When we say “interested parties” we mean:

 You

 Your heirs-at-law

 Your personal representative

 A provider

 Us

 Any agents, employees, or subcontractors of anyone listed above

If you cannot resolve your problem through the complaint processes described in the When you 

disagree – claim decisions and appeals procedures section you can ask for binding arbitration. Binding

arbitration is the final step you can take to resolve your complaint with us.

When you became a member, you agreed to submit all unresolved complaints to binding arbitration, 

including complaints about medical malpractice. This means that you have agreed to give up your right 

to a trial by jury and other legal proceedings. Your request should be submitted within 60 days of 

receiving our final determination notice and/or any independent medical review decision. 

Binding arbitration is a way to solve disputes, disagreements or problems without filing a formal lawsuit 

and:

 Is usually less expensive and takes less time than a lawsuit

 Can be requested by us or the interested parties 

Agreement to binding arbitration

A request for binding arbitration results in the following: 

 One or more people, called arbitrators, who are not connected with you or with us make the 

final decision on your case

 Together, you and Aetna choose and approve the arbitrators

 The arbitrators review the case and then write a decision, called an opinion

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 Both you and Aetna must accept (be bound by) the decision of the arbitrators

 There will be no right to a jury trial

 Any medical malpractice claims against your provider will not include us

 Any punitive damages award must be:

- Authorized

- Recoverable under applicable law

- Be based on clear evidence of our outrageous conduct

- Be reasonable in relation to the actual damages

 You cannot participate in any class action suits related to your coverage

How to request binding arbitration

To start the arbitration process you should contact the American Arbitration Association (AAA), or other 

neutral dispute resolution organization that we agree upon. The AAA can be reached by calling or 

writing:

 Los Angeles Regional Office

725 South Figueroa, Suite 400

Los Angeles, CA 90017

(213) 383-6516

 San Diego Regional Office

402 W. Broadway, Suite 400

San Diego, CA 92101

(619) 239-3051

 San Francisco Regional Office

One Sansome Street, Suite 1600

San Francisco, CA 94104

(415) 981-3901

 Customer service 1-800-778-7879

The AAA website is www.adr.org.

If the AAA declines the case or we do not agree on a different organization, then a neutral arbitrator 

shall be appointed upon petition to the court. You can decide where the arbitration is held.

Paying for binding arbitration 

You and Aetna share equally the fees and expenses of the arbitrator. If you cannot pay your part of the 

arbitrator’s fees and expenses, you may ask us to pay. For more information or an application for 

financial hardship, contact AAA or call the toll-free Member Services number on your member ID card.

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Coordination of benefits

Some people have health coverage under more than one health plan. If you do, we will work together 

with your other plan(s) to decide how much each plan pays. This is called coordination of benefits (COB).

Key terms

Here are some key terms we use in this section. These terms will help you understand this COB section.

Allowable expense means:

 A health care expense that any of your health plans cover to any degree. If the health care 

service is not covered by any of the plans, it is not an allowable expense. For example, cosmetic

surgery generally is not an allowable expense under this plan.

In this section when we talk about a “plan” through which you may have other coverage for health care 

expenses, we mean:

 Group or non-group, blanket, or franchise health insurance policies issued by insurers, HMOs, or

health care service contractors

 Labor-management trustee plans, labor organization plans, employer organization plans, or 

employee benefit organization plans

 An automobile insurance policy

 Medicare or other governmental benefits

 Any contract that you can obtain or maintain only because of membership in or connection with 

a particular organization or group

Here’s how COB works

 When this is the primary plan, we will pay your medical claims first as if the other plan does not 

exist. 

 When this is the secondary plan, we will pay benefits after the primary plan and will reduce the 

payment based on any amount the primary plan paid.

 We will never pay an amount that, together with payments from your other coverage, add up to 

more than 100% of the allowable expenses.

Determining who pays

Reading from top to bottom the first rule that applies will determine which plan is primary and which is 

secondary.

A plan that does not contain a COB provision is always the primary plan.

If you are covered as a: Primary plan Secondary plan

Non-dependent or Dependent The plan covering you as an 

employee or retired employee. 

The plan covering you as a 

dependent.

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Exception to the rule above 

when you are eligible for 

Medicare

If you or your spouse have Medicare coverage, the rule above may be 

reversed. If you have any questions about this you can contact us:

 Online: Log on to your secure member website at 

www.aetna.com. Follow the path to find a form. 

 By phone: Call the toll-free number on your ID card.

COB rules for dependent children

Child of:

 Parents who are married 

or living together

The “birthday rule” applies. The plan

of the parent whose birthday* 

(month and day only) falls earlier in 

the calendar year. 

*Same birthdays--the plan that has 

covered a parent longer is primary

The plan of the parent born 

later in the year (month and 

day only)*.

*Same birthdays--the plan 

that has covered a parent 

longer is primary

Child of:

 Parents separated or 

divorced or not living 

together

 With court-order

The plan of the parent whom the 

court said is responsible for health 

coverage.

But if that parent has no coverage 

then the other spouse’s plan.

The plan of the other parent.

But if that parent has no 

coverage, then his/her 

spouse’s plan is primary. 

Child of:

 Parents separated or 

divorced or not living 

together – court-order 

states both parents are 

responsible for coverage 

or have joint custody

Primary and secondary coverage is based on the birthday rule.

Child of:

 Parents separated or 

divorced or not living 

together and there is no 

court-order

The order of benefit payments is:

 The plan of the custodial parent pays first

 The plan of the spouse of the custodial parent (if any) pays second

 The plan of the noncustodial parent pays next

 The plan of the spouse of the noncustodial parent (if any) pays last

Child covered by: 

 Individual who is not a 

parent (i.e. stepparent 

or grandparent)

Treat the person the same as a parent when making the order of 

benefits determination: 

See Child of content above.

Active or inactive employee The plan covering you as an active 

employee (or as a dependent of an 

active employee) is primary to a plan 

covering you as a laid off or retired

employee (or as a dependent of a 

former employee).

A plan that covers the person 

as a laid off or retired 

employee (or as a dependent 

of a former employee) is 

secondary to a plan that 

covers the person as an active 

employee (or as a dependent 

of an active employee). 

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COBRA or state continuation The plan covering you as an 

employee or retiree or the 

dependent of an employee or 

retiree is primary to COBRA or state 

continuation coverage. 

COBRA or state continuation 

coverage is secondary to the 

plan that covers the person as 

an employee or retiree or the 

dependent of an employee or 

retiree.

Longer or shorter length of 

coverage

If none of the above rules determine the order of payment, the plan 

that has covered the person longer is primary.

Other rules do not apply If none of the above rules apply, the plans share expenses equally.

How are benefits paid?

Primary plan The primary plan pays your claims as if there is no 

other health plan involved.

Secondary plan The secondary plan calculates payment as if the 

primary plan did not exist and then applies that 

amount to any allowable expenses under the 

secondary plan that were not covered by the primary 

plan.

The secondary plan will reduce payments so the total 

payments do not exceed 100% of the total allowable 

expense.

Benefit reserve

each family member has a separate benefit 

reserve for each contract year

The benefit reserve:

 Is made up of the amount that the secondary plan 

saved due to COB

 Is used to cover any unpaid allowable expenses

 Balance is erased at the end of each year

How COB works with Medicare

This section explains how the benefits under this plan interact with benefits available under Medicare.

Medicare, when used in this plan, means the health insurance provided by Title XVIII of the Social 

Security Act, as amended. It also includes Health Maintenance Organization (HMO) or similar coverage 

that is an authorized alternative to Parts A and B of Medicare.

You are eligible for Medicare when you are covered under it by reason of:

 Age, disability, or

 End stage renal disease

When you are enrolled in Medicare, the plan coordinates the benefits it pays with the benefits that 

Medicare pays. Sometimes, this plan is the primary plan, which means that the plan pays benefits before 

Medicare pays benefits. Sometimes, this plan is the secondary plan, and pays benefits after Medicare or 

after an amount that Medicare would have paid had you been covered.

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Who pays first?

If you are enrolled due to 

age and have group health 

plan coverage based on 

your or your spouse’s 

current employment and:

Primary plan Secondary plan

The employer has 20 or more 

employees

Your plan Medicare

You are retired Medicare Your plan

If you have Medicare because of:

End stage renal disease (ESRD) Your plan will pay first for the 

first 30 months.

Medicare will pay first after 

this 30 month period.

Medicare

Your plan

A disability other than ESRD 

and your employer has more 

than 100 employees

Your plan Medicare

Note regarding ESRD: If you were already eligible for Medicare due to age and then became 

eligible due to ESRD, Medicare will remain your primary plan and this plan will be secondary.

This plan is secondary to Medicare in all other circumstances.

How are benefits paid?

We are primary We pay your claims as if there is no Medicare 

coverage. 

Medicare is Primary We calculate our benefit as if there were no 

Medicare coverage and reduce our benefit so 

that when combined with the Medicare 

payment, the total payment is no more than 

100% of the allowable expense.

Charges that satisfy your Part B deductible will be applied in the order received. We will apply the 

largest charge first when two or more charges are received at the same time.

Other health coverage updates – contact information

You should contact us if you have any changes to your other coverage. We want to be sure our records 

are accurate so your claims are processed correctly.

 Online: Log on to your secure member website at www.aetna.com. 

 By phone: Call the toll-free number on your ID card.

Right to receive and release needed information

We have the right to release or obtain any information we need for COB purposes. That includes 

information we need to recover any payments from your other health plans.

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Right to pay another carrier

Sometimes another plan pays something we would have paid under your plan. When that happens, we 

will pay your plan benefit to the other plan.

Right of recovery

If we pay more than we should have under the COB rules, we may recover the excess from:

 Any person we paid or for whom we paid; or

 Any other plan that is responsible under these COB rules.

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When coverage ends

Coverage can end for a number of reasons. This section tells you how and why coverage ends. And when 

you may still be able to continue coverage.

When will your coverage end?

Your coverage under this plan will end if:

 This plan is discontinued.

 You voluntarily stop your coverage.

 The group agreement ends.

 You are no longer eligible for coverage, including when you move out of the service area.

 Your employment ends. 

 You do not make any required contributions.

 We end your coverage.

 You become covered under another medical plan offered by your employer. 

When will coverage end for any dependents?

Coverage for your dependent will end if:

 Your dependent is no longer eligible for coverage.

 You do not make the required contribution toward the cost of dependents’ coverage.

 Your coverage ends for any of the reasons listed above (other than:

- If you enroll under a group Medicare + Choice plan that we offer. However, dependent’s 

coverage will end if your coverage ends under the Medicare + Choice plan

In addition, coverage for your domestic partner will end on the earlier of:

 The date this plan no longer allows coverage for domestic partners.

 The date the domestic partnership ends. You should provide your employer a completed and 

signed Declaration of Termination of Domestic Partnership.

What happens to your dependents if you die?

Coverage for dependents may continue for some time after your death. See the Special coverage 

options after your plan coverage ends section for more information.

Why would we end you and your dependents coverage?

We will give you 60 days advance written notice if we end your coverage because: 

 You do not cooperate or give facts that we need to administer the COB provisions.

We may also end your coverage if:

 Within 30 days after receipt of a certified written notice if you commit fraud or intentionally 

misrepresent yourself when you applied for or obtained coverage. You can refer to the A bit of 

this and that - Honest mistakes and intentional deception section for more information on 

rescissions.

 Any statement made is considered a representation and not a warranty. We will only use a 

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statement during a dispute if it is shared with you and your beneficiary, or the person making 

the claim.

On the date your coverage ends, we will refund to your employer any prepayments for periods after the 

date your coverage ended.

We will not end your coverage because of your health status or health care needs. We also will not end 

your coverage because you filed an appeal. If you believe we ended your coverage because of these 

things, you may request a review by the Director of the California Department of Managed Health Care. 

See the When you disagree – claim decisions and appeals procedures section. 

When will we send you a notice of your coverage ending?

We will send you notice if your coverage is ending. This notice will tell you the date that your coverage 

ends. Here is how the date is determined (other than the circumstances described above in “Why we 

would end your coverage”).

Your coverage will end on the day before the first premium contribution due date that occurs after you 

stop active work. 

Coverage will end for you and any dependents at the end of the month following the date on which you 

no longer meet the eligibility requirements.

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Special coverage options after your plan coverage ends

This section explains options you may have after your coverage ends under this plan. Your individual 

situation will determine what options you will have. 

Consolidated Omnibus Budget Reconciliation Act (COBRA) Rights

What are your COBRA rights?

COBRA gives some people the right to keep their health coverage for 18, 29 or 36 months after a 

“qualifying event”. COBRA usually applies to employers of group sizes of 20 or more. 

Here are the qualifying events that trigger COBRA continuation, who is eligible for continuation and how 

long coverage can be continued. 

Qualifying event causing 

loss of coverage

Covered persons eligible 

for continued coverage

Length of continued 

coverage

(starts from the day you 

lose current coverage)

Your active employment ends 

for reasons other than gross 

misconduct

You and your dependents 18 months

Your working hours are 

reduced

You and your dependents 18 months

You divorce or legally 

separate and are no longer 

responsible for dependent 

coverage

Your dependents 36 months

You become entitled to 

benefits under Medicare

Your dependents 36 months

Your covered dependent 

children no longer qualify as 

dependent under the plan

Your dependent children 36 months

You die Your dependents 36 months

You are a retiree eligible for 

retiree health coverage and 

your former employer files for 

bankruptcy

You and your dependents 18 months

When do I receive COBRA information?

The chart below lists who is responsible for giving the notice, the type of notice they are required to give 

and the timing.

Employer/Group health plan notification requirements

Notice Requirement Deadline

General notice – employer or Notify you and your Within 90 days after active 

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Aetna dependents of COBRA rights. employee coverage begins

Notice of qualifying event –

employer

Your active employment ends 

for reasons other than gross 

misconduct

Your working hours are 

reduced

You become entitled to 

benefits under Medicare

You die

You are a retiree eligible for 

retiree health coverage and 

your former employer files for 

bankruptcy

Within 30 days of the 

qualifying event or the loss of 

coverage, whichever occurs 

later

Election notice – employer or

Aetna

Notify you and your 

dependents of COBRA rights 

when there is a qualifying 

event

Within 14 days after notice of 

the qualifying event

Notice of unavailability of

COBRA – employer or Aetna

Notify you and your 

dependents if you are not 

entitled to COBRA coverage.

Within 14 days after notice of 

the qualifying event

Termination notice –

employer or Aetna

Notify you and your 

dependents when COBRA 

coverage ends before the end 

of the maximum coverage 

period.

As soon as practical following 

the decision that continuation 

coverage will end

You/your dependents notification requirements

Notice of qualifying event –

qualified beneficiary

Notify your employer if: 

 You divorce or legally 

separate and are no 

longer responsible for 

dependent coverage

 Your covered dependent 

children no longer qualify 

as a dependent under the 

plan

Within 60 days of the 

qualifying event or

the loss of coverage, 

whichever occurs later

Disability notice Notify your employer if:

 The Social Security 

Administration 

determines that you or a 

covered dependent 

Within 60 days of the decision 

of disability by the Social 

Security Administration, and 

before the 18 month 

coverage period ends

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qualify for disability status

Notice of qualified 

beneficiary’s status

change to non-disabled

Notify your employer if:

 The Social Security 

Administration decides 

that the beneficiary is no 

longer disabled

Within 30 days of the Social 

Security Administration’s 

decision

Enrollment in COBRA Notify your employer if:

 You are electing COBRA 

60 days from the qualifying 

event. You will lose your 

right to elect, if you do not:

 Respond within the 60 

days

 And send back your 

application

How can you extend the length of your COBRA coverage?

The chart below shows qualifying events after the start of COBRA (second qualifying events):

Qualifying event Person affected (qualifying 

beneficiary)

Total length of continued 

coverage

Disabled within the first 60 

days of COBRA coverage (as 

determined by the Social 

Security Administration)

You and your dependents 29 months (18 months plus 

an additional 11 months)

 You die

 You divorce or legally 

separate and are no 

longer responsible for 

dependent coverage

 You become entitled to 

benefits under Medicare

 Your covered dependent 

children no longer qualify 

as dependent under the 

plan

You and your dependents Up to 36 months

How do you enroll in COBRA?

You enroll by sending in an application and paying the premium. Your employer has 30 days to send you 

a COBRA election notice. It will tell you how to enroll and how much it will cost. You can take 60 days 

from the qualifying event to decide if you want to enroll. You need to send your application and pay the 

premium. If this is completed on time, you have enrolled in COBRA.

When is your first premium payment due?

Your first premium payment must be made within 45 days after the date of the COBRA election.

How much will COBRA coverage cost?

For most COBRA qualifying events you and your dependents will pay 102% of the total plan costs. This 

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additional 2% is added to cover administrative fees. If you apply for COBRA because of a disability, the 

total due will be 150% of the plan costs. 

Can you add a dependent to your COBRA coverage? 

You may add a new dependent during a period of COBRA coverage. They can be added for the rest of 

the COBRA coverage period if: 

 They meet the definition of an eligible dependent.

 You notified your employer within 31 days of their eligibility.

 You pay the additional required premiums.

When does COBRA coverage end?

COBRA coverage ends if:

 Coverage has continued for the maximum period.

 The plan ends. If the plan is replaced, you may be continued under the new plan.

 You and your dependents fail to make the necessary payments on time.

 You or a covered dependent become covered under another group health plan that does not 

exclude coverage for pre-existing conditions or the preexisting conditions exclusion does not 

apply.

 You or a covered dependent become entitled to benefits under Medicare.

 You or your dependents are continuing coverage during the 19th to 29th months of a disability, 

and the disability ends. 

Continuation of coverage for other reasons

To request an extension of coverage, just call the toll-free Member Services number on your ID card. 

How can you extend coverage if you are totally disabled when coverage ends?

Your coverage may be extended if you or your dependents are totally disabled when coverage ends. 

Only the medical condition which caused the total disability is covered during your extension.

You are “totally disabled” if you cannot work at your own occupation or any other occupation for pay or 

profit.

Your dependent is “totally disabled” if that person cannot engage in most normal activities of a healthy 

person of the same age and gender.

You may extend coverage only for services and supplies related to the disabling condition until the 

earliest of:

 When you or your dependents are no longer totally disabled

 When you become covered by another health benefits plan

 36 months of coverage

How can you extend coverage when getting inpatient care when coverage ends?

Your coverage may be extended if you or your dependents are getting inpatient care in a hospital or 

skilled nursing facility when coverage ends. 

Benefits are extended for the condition that caused the hospital or skilled nursing facility stay or for 

complications from the condition. Benefits aren’t extended for other medical conditions. 

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You can continue to get care for this condition until the earliest of:

 When you are discharged

 When you no longer need inpatient care

 When you become covered by another health benefits plan

 36 months of coverage

How can you extend coverage for your disabled child beyond the plan age limits?

You have the right to extend coverage for your dependent child beyond the plan age limits. If your 

disabled child:

 Is not able to be self-supporting because of mental or physical disability, and

 Depends mainly (more than 50% of income) on you for support.

The right to coverage will continue only as long as a physician certifies that your child still is disabled. 

We will send you a notice at least 90 days before your child reaches the plan age limit. We may ask you 

to send us proof of the disability within 90 days of the date coverage would have ended. Before we 

extend coverage, we may ask that your child get a physical exam. We will pay for that exam.

We may ask you to send proof that your child is disabled after coverage is extended. We won’t ask for 

this proof more than once every two years. You must send it to us within 31 days of our request. If you 

don’t, we can terminate coverage for your dependent child.

How can you extend coverage for a child in college on medical leave?

You have the right to extend coverage for your dependent college student who takes a medically 

necessary leave of absence from school. The right to coverage will be extended until:

 The earlier of one year after the leave of absence begins, or

 The date coverage would otherwise end.

To extend coverage the leave of absence must: 

 Begin while the dependent child is suffering from a serious illness or injury.

 Cause the dependent child to lose status as a full-time student under the plan, and

 Be certified by the treating doctor as medically necessary due to a serious illness or injury.

The doctor treating your child will be asked to keep us informed of any changes.

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A bit of this and that

We gathered a number of provisions here. They talk about several different things, so we call this part “a 

bit of this and that.” 

Administrative provisions

How you and we will interpret this EOC

We prepared this EOC according to ERISA, and according to other federal laws and state laws that apply. 

You and we will interpret it according to these laws. Also, you are bound by our interpretation of this 

EOC when we administer your coverage, so long as we use reasonable discretion.

How we administer this plan

We apply policies and procedures we’ve develop to administer this plan.

Who’s responsible to you

We are responsible to you for what our employees and other agents do. 

We are not responsible for what is done by your providers. Even network providers are not our 

employees or agents. 

Coverage and services

Your coverage can change 

Your coverage is defined by the HMO agreement. This document may have amendments or riders too. 

Under certain circumstances, we or your employer or the law may change your plan. Only Aetna may 

waive a requirement of your plan. No other person – including your employer or provider – can do this.

If a service cannot be provided to you

Sometimes things happen that are outside of our control. These are things such as natural disasters, 

epidemics, fire and riots. 

We will try hard to get you access to the services you need even if these things happen. But if we can’t, 

we may refund you or your employer any unearned premium.

Legal action 

You cannot take any legal action against Aetna until 60 days after we receive written submission of 

claim.

Honest mistakes and intentional deception

Honest mistakes

You or your employer may make an honest mistake in your application for coverage. When we learn of 

the mistake, we may make a fair change in premium contribution or in your coverage. If we do, we will 

tell you what the mistake was. We won’t make a change if the mistake happened more than 2 years 

before we learned of it.

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Intentional deception 

If we learn that you defrauded us or you intentionally misrepresented material facts, we can take 

actions that can have serious consequences for your coverage. These serious consequences include, but 

are not limited to:

 Loss of coverage, starting at some time in the past. This is called rescission.

 Loss of coverage going forward.

 Denial of benefits.

 Recovery of amounts we already paid.

We also may report fraud to criminal authorities.

Rescission means you lose coverage both going forward and going backward. If we paid claims for your 

past coverage, we will want the money back. 

You have special rights if we rescind your coverage.

 We will give you 30 days advanced written notice of any rescission of coverage.

 You have the right to an Aetna appeal.

 You have the right to a third party review conducted by the California Department of Managed 

Health Care.

Some other money issues

Assignment of benefits

When you see a network provider they will usually bill us directly. When you see an out-of-network

provider we may choose to pay you or to pay the provider directly. You do not have the right to assign 

your benefits or any rights under this plan to an out-of-network provider.

Financial sanctions exclusions

If coverage provided under this certificate violates or will violate any economic or trade sanctions, the 

coverage will be invalid immediately. For example, we cannot pay for eligible health services if it violates 

a financial sanction regulation. This includes sanctions related to a person or a country under sanction 

by the United States, unless it is allowed under a written license from the Office of Foreign Asset Control 

(OFAC). You can find out more by visiting http://www.treasury.gov/resourcecenter/sanctions/Pages/default.aspx.

Recovery of overpayments

We sometimes pay too much for eligible health services or pay for something that this plan doesn’t 

cover. If we do, we can require the person we paid – you or your provider – to return what we paid. If 

we don’t do that we have the right to reduce any future benefit payments by the amount we paid by 

mistake.

When you are injured

If someone else caused you to need care – say, a careless driver who injured you in a car crash – you 

may have a right to get money. We are entitled to that money, based on the reasonable cost of benefits

we pay for your care. We have that right no matter who the money comes from – for example, the other 

driver, your employer or another insurance company.

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To help us get paid back, you are doing four things now:

 You are agreeing to repay us from money you receive because of your injury.

 You are giving us a right to seek money in your name, from any person who causes you injury

and from your own insurance. We can seek money only up to the amount we paid for your care. 

 You are agreeing to cooperate with us so we can get paid back in full. For example, you’ll tell us 

within 30 days of when you seek money for your injury or illness. You’ll hold any money you 

receive until we are paid in full. And you’ll give us the right to money you get, ahead of everyone 

else.

 You are agreeing to provide us notice of any money you will be receiving before pay out, or 

within 5 days of when you receive the money.

The amount of the money can be reduced if a judge, jury, or arbitrator decides you had some fault for 

the injury. 

The amount of the money owed will not exceed one-third of the recovery, settlement, judgment or 

other source of compensation if you have an attorney or one-half of the recovery, settlement, judgment 

or other source of compensation if you did not have an attorney. 

Sometimes your provider may also be entitled to that money. If your provider has been paid capitation, 

the lien will be limited to 80% of the usual and customary charge for the same service charged in the 

geographic region on a fee for service basis.

Your health information

We will protect your health information. We use and share it to help us process your providers’ claims 

and manage your plan.

You can get a free copy of our Notice of Privacy Practices, by calling the toll-free number on your ID 

card.

When you accept coverage under this plan, you agree to let your providers share your information with 

us. We need information about your physical and mental condition and care.

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Glossary

Aetna

Aetna Health of California Inc., a California corporation holding a certificate of authority from the 

California Department of Managed Health Care as a health maintenance organization, operating 

according to Chapter 2.2 of Division 2 of the Health and Safety Code (commencing with Section 1340), 

commonly known as the Knox-Keene Health Care Service Plan Act of 1975.

Ambulance

A vehicle staffed by medical personnel and equipped to transport an ill or injured person. 

Behavioral health provider

An individual professional that is properly licensed or certified to provide diagnostic and/or therapeutic 

services for mental disorders and substance abuse under the laws of the jurisdiction where the 

individual practices. Also includes qualified autism service providers, qualified autism service 

professionals and qualified autism service paraprofessionals

Body mass index

This is a degree of obesity and is calculated by dividing your weight in kilograms by your height in meters 

squared.

Brand-name prescription drug

A U.S. Food and Drug Administration (FDA) approved prescription drug marketed with a specific brand 

name by the company that manufactures it, usually by the company which develops and patents it.

Coinsurance

The specific percentage you have to pay for a health care service listed in the schedule of benefits.

Contract year

A period of 1 year beginning on the contract holder’s effective date of coverage.

Copay, copayments

The specific dollar amount you have to pay for a health care service listed in the schedule of benefits.

Cosmetic

Services, drugs or supplies that are primarily intended to alter, improve or enhance your appearance.

Covered benefits 

Eligible health services that meet the requirements for coverage under the terms of this plan, including:

1. They are medically necessary.

2. You received precertification and/or a referral, if required.

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Custodial care

Services and supplies mainly intended to help meet your activities of daily living or other personal 

needs. Care may be custodial care even if it is prescribed by a physician or given by trained medical 

personnel. 

Deductible

The amount you pay for eligible health services per contract year before your plan starts to pay as listed 

in the schedule of benefits.

Detoxification

The process where an alcohol or drug intoxicated, or alcohol or drug dependent, person is assisted 

through the period of time needed to eliminate the: 

 Intoxicating alcohol or drug

 Alcohol or drug-dependent factors

 Alcohol in combination with drugs

This could be done by metabolic or other means determined by a physician. The process must keep the 

physiological risk to the patient at a minimum. And if it takes place in a facility, the facility must meet any 

applicable licensing standards established by the jurisdiction in which it is located.

Directory

The list of network providers for your plan. The most up-to-date directory for your plan appears at 

www.aetna.com under the provider search label. When searching provider search, you need to make 

sure that you are searching for providers that participate in your specific plan. Network providers may 

only be considered for certain Aetna plans. 

Durable medical equipment (DME)

Equipment and the accessories needed to operate it, that is:

 Made to withstand prolonged use

 Mainly used in the treatment of an illness or injury

 Suited for use in the home

 Not normally used by people who do not have an illness or injury

 Not for altering air quality or temperature

 Not for exercise or training

Effective date of coverage

The date you and your dependents coverage begins under this EOC as noted in Aetna’s records.

Eligible health services

The health care services and supplies listed in the Eligible health services under your plan section and 

not carved out or limited in the exceptions section or in the schedule of benefits.

Emergency admission

An admission to a hospital or treatment facility ordered by a physician within 24 hours after you receive 

emergency services.

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Emergency medical condition

A medical condition (including severe pain) that would lead you to reasonably believe that the condition, 

illness, or injury is of a severe nature. And that if you don’t get immediate medical care it could result in:

 Placing your health in serious danger

 Serious loss to bodily function

 Serious loss of function to a body part or organ

 Serious danger to the health of a fetus (including a pregnant woman in active labor)

A mental health condition is also an emergency medical condition when, due to a mental disorder, either 

of the following is true: 

 You are an immediate danger to yourself or to others

 You are immediately unable to provide for or use food, shelter, or clothing due to the mental 

disorder

Emergency services

Treatment given in a hospital’s emergency room for an emergency medical condition. This includes 

evaluation of, and treatment to stabilize an emergency medical condition.

Experimental or investigational

A drug, device, procedure, or treatment that we find is experimental or investigational because:

 There is not enough outcome data available from controlled clinical trials published in the peerreviewed literature to validate its safety and effectiveness for the illness or injury involved

 The needed approval by the FDA has not been given for marketing

 A national medical or dental society or regulatory agency has stated in writing that it is 

experimental or investigational or suitable mainly for research purposes

 It is the subject of a Phase I, Phase II or the experimental or research arm of a Phase III clinical 

trial. These terms have the meanings given by regulations and other official actions and 

publications of the FDA and Department of Health and Human Services

 Written protocols or a written consent form used by a facility provider state that it is

experimental or investigational. 

Formulary exclusions list

A list of prescription drugs not covered under the plan. This list is subject to change.

Generic prescription drug

A prescription drug with the same dosage, safety, strength, quality, performance and intended use as 

the brand name product. It is defined as therapeutically equivalent by the U.S. Food and Drug 

Administration (FDA) and is considered to be as effective as the brand-name product.

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HMO agreement

The HMO agreement consists of several documents taken together. These documents are:

 The group application

 The group agreement

 The EOC(s) attached

 The schedule of benefits attached

 Any riders and amendments to the group agreement, the EOC, and the schedule of benefits

Health professional

A person who is licensed, certified or otherwise authorized by law to provide health care services to the 

public. For example, physicians, nurses, and physical therapists.

Home health care agency

An agency licensed, certified or otherwise authorized by applicable state and federal laws to provide 

home health care services, such as skilled nursing and other therapeutic services.

Home health care plan

A plan of services prescribed by a physician or other health care practitioner to be provided in the home 

setting. These services are usually provided after your discharge from a hospital or if you are 

homebound. 

Hospice care

Care designed to give supportive care to people in the final phase of a terminal illness and focus on 

comfort and quality of life, rather than cure.

Hospice care agency

An agency or organization licensed, certified or otherwise authorized by applicable state and federal 

laws to provide hospice care. These services may be available in your home or inpatient setting.

Hospice care program

A program prescribed by a physician or other health professional to provide hospice care and 

supportive care to their families.

Hospice facility

An institution specifically licensed, certified or otherwise authorized by applicable state and federal laws 

to provide hospice care.

Hospital

An institution licensed as a hospital by applicable state and federal laws, and is accredited as a hospital

by The Joint Commission (TJC).

Hospital does not include a: 

 Convalescent facility

 Rest facility

 Nursing facility

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 Facility for the aged

 Psychiatric hospital

 Residential treatment facility for substance abuse

 Residential treatment facility for mental disorders 

 Extended care facility

 Intermediate care facility

 Skilled nursing facility

Illness

Poor health resulting from disease of the body or mind.

Infertile or infertility

A disease defined by the failure to conceive a pregnancy after 12 months or more of timed intercourse 

or egg-sperm contact for women under age 35 (or 6 months for women age 35 or older).

Injury

Physical damage done to a person or part of their body.

Institutes of ExcellenceTM (IOE) facility

A facility designated by Aetna in the provider directory as Institutes of Excellence network provider for 

specific services or procedures.

Intensive Outpatient Program (IOP)

Clinical treatment provided in a facility or program provided under the direction of a physician. Services 

are designed to address a mental disorder or substance abuse issue and may include group, individual, 

family or multi-family group psychotherapy, psycho educational services, and adjunctive services such as 

medication monitoring.

Jaw joint disorder

This is:

 A temporomandibular joint (TMJ) dysfunction or any similar disorder of the jaw joint 

 A myofascial pain dysfunction (MPD) of the jaw, or

 Any similar disorder in the relationship between the jaw joint and the related muscles and 

nerves.

L.P.N.

A licensed practical nurse or a licensed vocational nurse.

Mail order pharmacy

A pharmacy where prescription drugs are legally dispensed by mail or other carrier.

Maximum out-of-pocket limit

The maximum out-of-pocket amount for payment of copayments and coinsurance to be paid by you or 

any covered dependents per calendar year for eligible health services. 

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Medically necessary/Medical necessity

Health care services that we determine a provider exercising prudent clinical judgment, would provide 

to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease 

or its symptoms, and that we determine are:

 In accordance with 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

 Not more costly than an alternative service or sequence of services at least as likely to produce 

equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s 

illness, injury or disease 

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.

 Consistent with the standards set forth in policy issues involving clinical judgment.

Mental disorder

An illness commonly understood to be a mental disorder, whether or not it has a physiological or 

organic basis, and for which treatment is generally provided by or under the direction of a behavioral 

health provider such as a psychiatrist, a psychologist or a psychiatric social worker. Mental disorder

includes substance related disorders.

Morbid obesity/morbidly obese

This means the body mass index is well above the normal range and severe medical conditions may also 

be present, such as:

• High blood pressure

• A heart or lung condition 

• Sleep apnea or

• Diabetes

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Negotiated charge

As to health coverage, (other than prescription drug coverage for services obtained from a network 

pharmacy): 

The amount a network provider has agreed to accept for rendering services or providing prescription 

drugs or supplies to members of your plan.

As to prescription drug coverage when prescription drugs are obtained from a network pharmacy: 

The amount Aetna has established for each prescription drug obtained from a network pharmacy 

under this plan. This negotiated charge may reflect amounts Aetna has agreed to pay directly to the 

network pharmacy or to a third party vendor for the prescription drug, and may include an additional 

service or risk charge set by Aetna.

The negotiated charge does not reflect any amount Aetna, an affiliate, or a third party vendor, may 

receive under a rebate arrangement between Aetna, an affiliate or a third party vendor and a drug 

manufacturer for any prescription drug, including prescription drugs on the preferred drug guide.

Aetna may receive rebates from the manufacturers of prescription drugs and may receive or pay 

additional amounts from or to third parties under price guarantees. These amounts will not change the 

negotiated charge under this plan.

Network pharmacy

A retail, mail order or specialty pharmacy that has contracted with Aetna, an affiliate, or a third party 

vendor, to provide outpatient prescription drugs to you.

Network provider

A provider listed in the directory for your plan. However, a National Advantage Program (NAP) provider 

listed in the NAP directory is not a network provider. The NAP network consists of many of Aetna’s 

directly contracted hospitals, ancillary providers, and physicians as well as hospitals, ancillary 

providers, and physicians accessed through vendor arrangements.

Partial hospitalization treatment

A plan of medical, psychiatric, nursing, counseling, or therapeutic services to treat mental disorders and 

substance abuse. The treatment plan must meet these tests:

 It is carried out in a hospital, psychiatric hospital or residential treatment facility on less than a 

full-time inpatient basis.

 It is in accordance with accepted medical practice for the condition of the person.

 It does not require full-time confinement.

 It is supervised by a psychiatrist who weekly reviews and evaluates its effect.

Physician 

A skilled health care professional trained and licensed to practice medicine under the laws of the state 

where they practice; specifically, doctors of medicine or osteopathy.

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Precertification, precertify

A requirement that your physician contact Aetna before you receive coverage for certain services. This 

may include a determination by us as to whether the service is medically necessary and eligible for 

coverage.

Preferred drug

A prescription drug or device that may have a lower out-of-pocket cost than a non-preferred drug.

Preferred drug guide

A list of prescription drugs and devices established by Aetna or an affiliate. It does not include all 

prescription drugs and devices. This list can be reviewed and changed by Aetna or an affiliate. The 

Therapeutics Committee reviews the preferred drug guide annually. Throughout the year, the 

Therapeutics Committee may also evaluate new drugs once they are approved by the FDA, and may reevaluate the drugs on the current preferred drug guide in light of new FDA, manufacturer, and/or peer 

reviewed information. Further information about the Therapeutics Committee is located in the 

preferred drug guide. A copy of the preferred drug guide is available at your request. Or you can find it 

on the Aetna website at www.aetna.com/formulary.

Preferred network pharmacy

A network retail pharmacy that Aetna has identified as a preferred network pharmacy.

Premium

The amount you or your employer are required to pay to Aetna to continue coverage.

Prescriber

Any provider acting within the scope of his or her license, who has the legal authority to write an order 

for outpatient prescription drugs.

Prescription

As to prescription drugs:

A written order for the dispensing of a prescription drug by a prescriber. If it is a verbal order, it must 

promptly be put in writing by the network pharmacy.

Prescription drug

An FDA approved drug or biological which can only be dispensed by prescription.

Primary care physician (PCP)

A physician who:

 The directory lists as a PCP Is selected by a person from the list of PCPs in the directory

 Supervises, coordinates and provides initial care and basic medical services to a person as a 

general or family care physician, an internist, obstetrician, gynecologist or a pediatrician

 Initiates referrals for specialist care and maintains continuity of patient care

 Is shown on Aetna's records as your PCP

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Provider

A physician, other health professional, hospital, skilled nursing facility, home health care agency or 

other entity or person licensed or certified under applicable state and federal law to provide health care 

services to you. If state law does not specifically provide for licensure or certification, the entity must 

meet all Medicare accreditation standards (even if it does not participate in Medicare).

Psychiatric hospital

An institution specifically licensed as a psychiatric hospital by applicable state and federal laws to 

provide a program for the diagnosis, evaluation, and treatment of alcoholism, drug abuse, mental

disorders or mental illnesses.

Psychiatrist

A psychiatrist generally provides evaluation and treatment of mental, emotional, or behavioral 

disorders.

R.N.

A registered nurse.

Referral

This is a written or electronic authorization made by your PCP to direct you to a network provider for 

medically necessary services and supplies.

Residential treatment facility (mental disorders) 

 An institution specifically licensed as a residential treatment facility by applicable state and 

federal laws to provide for mental health residential treatment programs. And is credentialed by 

Aetna or is accredited by one of the following agencies, commissions or committees for the 

services being provided: 

- The Joint Commission (TJC)

- The Committee on Accreditation of Rehabilitation Facilities (CARF)

- The American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP)

- The Council on Accreditation (COA)

In addition to the above requirements, an institution must meet the following for residential treatment 

programs treating mental disorders:

 A behavioral health provider must be actively on duty 24 hours per day for 7 days a week.

 The patient must be treated by a psychiatrist at least once per week.

 The medical director must be a psychiatrist.

 Is not a wilderness treatment program (whether or not the program is part of a licensed 

residential treatment facility or otherwise licensed institution).

Residential treatment facility (substance abuse)

 An institution specifically licensed as a residential treatment facility by applicable state and 

federal laws to provide for substance abuse residential treatment program and is credentialed 

by Aetna or accredited by one of the following agencies, commissions or committees for the 

services being provided: 

- The Joint Commission (TJC)

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- The Committee on Accreditation of Rehabilitation Facilities (CARF)

- The American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP)

- The Council on Accreditation (COA)

In addition to the above requirements, an institution must meet the following for Chemical Dependence 

Residential Treatment Programs:

 A behavioral health provider or an appropriately state certified professional (CADC, CAC, etc.) 

must be actively on duty during the day and evening therapeutic programming.

 The medical director must be a physician.

 Is not a wilderness treatment program (whether or not the program is part of a licensed 

residential treatment facility or otherwise licensed institution).

In addition to the above requirements, for Chemical Dependence Detoxification Programs within a 

residential setting:

 An R.N. must be onsite 24 hours per day for 7 days a week within a residential setting.

 Residential care must be provided under the direct supervision of a physician.

Retail pharmacy

A community pharmacy that dispenses outpatient prescription drugs at retail prices.

Room and board

A facility’s charge for your overnight stay and other services and supplies expressed as a daily or weekly 

rate.

Semi-private room rate

An institution’s room and board charge for most beds in rooms with 2 or more beds. If there are no 

such rooms, Texas Health + Aetna Health will calculate the rate based on the rate most commonly 

charged by similar institutions in the same geographic area.

Service area

The geographic area where network providers for this plan are located. 

Skilled nursing facility

A facility specifically licensed as a skilled nursing facility by applicable state and federal laws to provide 

skilled nursing care.

Skilled nursing facilities also include rehabilitation hospitals, and portions of a rehabilitation hospital

and a hospital designated for skilled or rehabilitation services.

Skilled nursing facility does not include institutions that provide only:

• Minimal care

• Custodial care services

• Ambulatory care

• Part-time care services

It does not include institutions that primarily provide for the care and treatment of mental disorders or 

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substance abuse.

Skilled nursing services

Services provided by an R.N. or L.P.N. within the scope of his or her license. 

Specialist

A physician who practices in any generally accepted medical or surgical sub-specialty.

Stay

A full-time inpatient confinement for which a room and board charge is made.

Step therapy

A form of precertification under which certain prescription drugs will be excluded from coverage, unless 

a first-line therapy drug(s) is used first by you. The list of step-therapy drugs is subject to change by 

Aetna or an affiliate. An updated copy of the list of drugs subject to step therapy shall be available upon 

request by you or may be accessed on the Aetna website at www.aetna.com/formulary.

Substance abuse

This is a physical or psychological dependency, or both, on a controlled substance or alcohol agent. 

These are defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the 

American Psychiatric Association. This term does not include conditions that you cannot attribute to a 

mental disorder that are a focus of attention or treatment. Or an addiction to nicotine products, food or 

caffeine intoxication.

Surgery center

A facility specifically licensed as a freestanding ambulatory surgical facility by applicable state and 

federal laws to provide outpatient surgery services. If state law does not specifically provide for 

licensure as an ambulatory surgical facility, the facility must meet all Medicare accreditation standards 

(even if it does not participate in Medicare).

Surgery or surgical procedures

The diagnosis and treatment of injury, deformity and disease by manual and instrumental means, such 

as cutting, abrading, suturing, destruction, ablation, removal, lasering, introduction of a catheter (e.g., 

heart or bladder catheterization) or scope (e.g., colonoscopy or other types of endoscopy), correction of 

fracture, reduction of dislocation, application of plaster casts, injection into a joint, injection of 

sclerosing solution, or otherwise physically changing body tissues and organs.

Telemedicine 

A telephone or internet-based consult with a provider that has contracted with Aetna to offer these 

services. 

Terminal illness

A medical prognosis that you are not likely to live more than 12 months.

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Therapeutic drug class

A group of drugs or medications that have a similar or identical mode of action. Or are used for the 

treatment of the same or similar disease or injury. 

Urgent care facility

A facility licensed as a freestanding medical facility by applicable state and federal laws to treat an 

urgent condition.

Urgent condition

An illness or injury that requires prompt medical attention but is not an emergency medical condition.

Value Prescription Drugs 

A group of medications determined by us that may be available at a reduced copayment/coinsurance

and are noted on the preferred drug guide.

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Discount programs

Discount arrangements

We can offer you discounts on health care related goods or services. Sometimes, other companies 

provide these discounted goods and services. These companies are called “third party service 

providers”. These third party service providers may pay us so that they can offer you their services. 

Third party service providers are independent contractors. The third party service provider is 

responsible for the goods or services they deliver. We are not responsible. But, we have the right to 

change or end the arrangements at any time. 

These discount arrangements are not insurance. We don’t pay the third party service providers for the 

services they offer. You are responsible for paying for the discounted goods or services.

Wellness and other incentives

We may encourage you to access certain medical services, use tools (online and others) that enhance

your coverage and services, and continue participation as an Aetna member through incentives. You 

and your doctor can talk about these medical services and tools and decide if they are right for you. In 

connection with a wellness or health improvement program, we may provide incentives based on your 

participation and your results. Incentives may include:

 Modifications to copayment, deductible, or coinsurance amounts 

 Premium discounts or rebates 

 Contributions to a health savings account

 Fitness center membership reimbursement

 Merchandise

 Coupons

 Gift cards

 Debit cards, or 

 Any combination of the above.

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New Law Protects Consumers from Surprise Medical Bills

A new law created by Assembly Bill (AB) 72i(Bonta, Chapter 492, Statutes of 2016) protects consumers

from surprise medical bills when they go to in-network facilities such as hospitals, labs or imaging 

centers. This new consumer protection starts July 1, 2017, and makes sure consumers only have to pay

their in-network cost sharing.

Providers now cannot send consumers out-of-network bills when the consumer did everything right and

went to an in-network facility.

Frequently Asked Questions:

What is a surprise bill, and why would I get one?

Here are some examples of when consumers have gotten surprise bills:

 A consumer had a surgery at a hospital or outpatient surgery center in their health plan

network, but the anesthesiologist was not in their health plan network. Even though the

consumer did not have a choice in who their anesthesiologist was, that provider sends a

bill to the consumer after the surgery. This is a surprise bill.

 A consumer goes to a lab or imaging center in their health plan network for tests and

the doctor who reads the results is not in their health plan network. That doctor then

bills the consumer for their services creating a surprise bill for the consumer.

Under AB 72, consumers should no longer receive these surprise bills. This means when you go

to a health care facility like a hospital or a lab in your health plan network, and end up with a

doctor who is not in your health plan network, they cannot charge you more than you would

have to pay for an in-network doctor.

Consumer Quick Facts:

 No Surprise Medical Bills: Health care consumers are no longer put in the middle

of billing disputes between health plans and out-of-network providers. Consumers

can only be billed for their in-network cost-sharing, when they use an in-network

facility.

 Prevents Collections: Protects consumers from having their credit hurt,

wages garnished, or liens placed on their primary residence.

 Helps Control Health Care Costs: Health plan payments for out-of-network

services are no longer based on sticker price.

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What should I pay?

Consumers who go to an in-network facility only have to pay for in-network cost-sharing (copays, co-insurance, or deductibles). Consumers should contact their health plan if they have

questions about their in-network cost-sharing.

What is a Health Plan Network?

A health plan network is the group of doctors, hospitals and other health care providers a

health plan contracts with to provide health care services to its members. These providers are

called “network providers,” “contracted providers” or “in-network providers.” A provider who

does not contract with your health plan is called an “out-of- network provider” or “noncontracted providers.”

Examples of health care facilities that are in a health plan network include hospitals,

ambulatory surgery centers or other outpatient settings, laboratories, and radiology or

imaging centers.

What If I Received a Surprise Bill? And what if I Already Paid?

If you received a surprise bill and already paid more than your in-network cost share (co-pay,

co-insurance or deductible), file a grievance/complaint with your health plan with a copy of

the bill. Your health plan will review your grievance and should tell the provider to stop billing 

you. If you do not agree with your health plan’s response or they take more than 30 days to fix

the problem, you can file a complaint with the Department

of Managed Health Care, the state regulator of health plans. You can file a complaint by

visiting www.HealthHelp.ca.gov or calling 1-888-466-2219.

Does the New Law Apply to Everyone?

The law applies to people in health plans regulated by the Department of Managed Health

Care or the California Department of Insurance. It does not apply to Medi-Cal plans, Medicare 

plans or “self-insured plans.” If you do not know what kind of plan you are in you can call the 

Help Center at 1-888-466-2219 for help.

What If I Want to See a Doctor Who I Know is Out-of-Network?

If you are in a health plan with an out-of-network benefit, such as a PPO, you can choose to go

to an out-of-network provider. You have to give your permission by signing a form in writing 

at least 24 hours before you receive care. The form should inform you that you can receive

care from an in-network provider if you so choose. The form should be in your language if you

speak English, Spanish, Vietnamese, Cantonese, Armenian, Russian, Mandarin, Tagalog,

Korean, Arabic, Hmong, Farsi, or Cambodian.

i

AB 72 protects consumersreceiving non-emergency services at in-network facilitiesfrom being balanced billed by

an out-of-network provider. California law already protects most consumersfrom balance billing for emergency

services.

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Important Information about the Affordable Care Act (ACA)

Non-discrimination Rule

The Office of Civil Rights recently issued a Non-discrimination Rule in response to Section 1557 of the 

Affordable Care Act (ACA). Section 1557 prohibits discrimination because of race, color, national origin, 

sex, age or disability in health-related insurance or other health-related coverage. This applies to Aetna. 

Changes to health insurance plans are effective on the first day of the policy or plan year beginning on or 

after January 1, 2017.

Some language changes may not be in the enclosed certificate of coverage or policy. This may be 

because the language is still under official review for approval. See the Important note below for how 

this affects your policy or plan. 

Important note:

We will comply with the requirements of the Rule for all new and renewing policies or plans with an 

effective date on or after January 1, 2017. 

Below is a summary of some of the recent Non-discrimination Rule changes.

An insurer covered by the Rule that provides or administers health-related insurance or other healthrelated coverage:

 Shall not:

o Cancel, limit or refuse to issue or renew a policy or plan

o Deny or limit coverage of a claim 

o Apply additional cost sharing

to a person because of race, color, national origin, sex, age, or disability.

 Shall not:

o Deny or limit coverage

o Deny or limit coverage of a claim 

o Apply additional cost sharing

to a transgender person, if it results in discrimination against that person.

 Shall not exclude or limit health services related to gender transition.

Aetna is the brand name used for products and services provided by one or more of the Aetna group 

of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and 

their affiliates. Aetna companies that receive funds from the federal Department of Health and 

Human Services are subject to the Rule.

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Important Information About Your Plan

Coverage of Applied Behavior Analysis

For the Treatment of Autism Spectrum Disorder

Your Plan includes coverage for the diagnosis and treatment of autism spectrum disorder. Eligible health 

services include the services and supplies provided by a physician or behavioral health provider for the 

diagnosis and treatment of autism spectrum disorder.

As part of this coverage, we will cover certain early intensive behavioral interventions, such as applied 

behavior analysis. Applied behavior analysis is an educational service that is the process of applying 

interventions:

• That systematically change behavior, and

• That are responsible for observable improvements in behavior.

Applied behavioral analysis will be subject to the same cost sharing requirements as other, outpatient 

services provided by a behavioral health provider for the treatment of autism spectrum disorder.

Important notes:

For plans that did not include such coverage previously, applied behavior analysis for the treatment 

of autism spectrum disorder will be an eligible health service for all new and renewing policies or 

plans with an effective date on or after January 1, 2017.

Applied behavior analysis requires precertification by Aetna.

Aetna is the brand name used for products and services provided by one or more of the Aetna group 

of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and 

their affiliates.

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HI Rider00040 01 1 CA

Aetna Health of California Inc.

Rider

Incentive

Rider effective date: January 01, 2019

This incentive rider is added to your evidence of coverage (EOC). This rider is subject to all of the 

requirements described in your EOC. This rider describes your incentive benefit, subject to the following 

requirements:

What you need to know about your incentive benefit

Read this rider carefully so that you know:

 What an incentive is

 Your incentive benefits

What an incentive is

You and your covered dependent spouse, or domestic partner, may earn a reward for participating in 

certain activities listed below. In order to receive your incentive all of the following steps must be done:

 Log onto your secure member website at www.aetna.com and access the Redbrick Compass® 

site or call the toll-free Member Services number on your member ID card.

 Complete a health assessment. A health assessment is a comprehensive questionnaire that can 

help you learn more about your health risks and how you can control them. A series of 

questions will be asked about things such as blood pressure, cholesterol levels, triglyceride level 

and blood sugar. This information can be obtained from your doctor during your annual 

physical.

 After you complete your health assessment, you will be eligible to participate in activities that 

align with your results. A list of these activities is available from us or your contract holder. To 

contact us, log onto your secure member website at www.aetna.com, or call Member Services 

at the number on your ID card.

 Once you complete your health assessment and one activity, you will receive your incentive 

amount. The type and value of your incentive amount and the incentive maximum are chosen 

by the contract holder.

• The incentive amount is shown in the schedule of benefits below.

Your plan may also have an incentive maximum per calendar year. The incentive amount and the 

incentive maximum are shown in the schedule of benefits below.

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Schedule of benefits

Your incentive benefits

Plan features Incentive amount/Maximums

Incentive amount $50 per calendar year.

Individual incentive maximum $50 per calendar year.

Family incentive maximum $100 per calendar year.

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AETNA HEALTH OF CALIFORNIA INC.

Rider

Outpatient prescription drug plan

Rider effective date: January 01, 2019

This prescription plan rider is added to your evidence of coverage (EOC). This rider is subject to all of the 

requirements described in your EOC. This rider describes your outpatient prescription drug plan benefit, 

subject to the following requirements:

What you need to know about your outpatient prescription drug plan

Read this rider carefully so that you know:

 How to access network pharmacies

 Eligible health services under your plan

 What outpatient prescription drugs are covered 

 Other services

 How you get an emergency prescription filled

 Where your schedule of benefits fits in

 What precertification requirements apply

 What your plan doesn’t cover – some eligible health service exceptions

 How you share the cost of your outpatient prescription drugs 

Some prescription drugs may not be covered or coverage may be limited. This does not keep you from 

getting prescription drugs that are not covered benefits. You can still fill your prescription, but you have 

to pay for it yourself. For more information see the Where your schedule of benefits fits in section, and 

see the schedule of benefits.

A pharmacy may refuse to fill a prescription order or refill when in the professional judgment of the 

pharmacist the prescription should not be filled.

How to access network pharmacies

How do you find a network pharmacy?

You can find a network pharmacy in two ways:

 Online: By logging onto your secure member website at www.aetna.com.

 By phone: Call the toll-free Member Services number on your member ID card. During regular 

business hours, a Member Services representative can assist you. Our automated telephone 

assistant can give you this information 24 hours a day.

You may go to any of our network pharmacies. Pharmacies include network retail, mail order and 

specialty pharmacies.

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What if the pharmacy you have been using leaves the network?

Sometimes a pharmacy might leave the network. If this happens, you will have to get your 

prescriptions filled at another network pharmacy. You can use your provider directory or call 

the toll-free Member Services number on your member ID card to find another network 

pharmacy in your area.

Eligible health services under your plan

What does your outpatient prescription drug plan cover?

Any pharmacy service that meets these three requirements:

• They are listed in the Eligible health services under your plan section.

• They are not carved out in the What your plan doesn’t cover - some eligible health service

 exceptions section.

• They are not beyond any limits in the schedule of benefits below.

Your plan benefits are covered when you follow the plan’s general rules:

 You need a prescription from your prescriber.

 Your drug needs to be medically necessary for your illness or injury. See the Medical necessity , 

referral and precertification requirements section.

 You need to show your ID card to the pharmacy when you get a prescription filled.

Your outpatient prescription drug plan includes drugs listed in the drug guide. Prescription drugs listed 

on the formulary exclusions list are excluded unless a medical exception is approved by us prior to the 

drug being picked up at the pharmacy. If it is medically necessary for you to use a prescription drug on 

the formulary exclusions list, you or your prescriber must request a medical exception.

The drug guide (formulary) contains drugs that have been reviewed by Aetna’s Pharmacy and 

Therapeutics Committee. This Committee:

 Reviews the entire drug guide (formulary) at least annually. 

 Meets regularly to review new drugs and new information about drugs that already are in the 

marketplace. 

 Reviews available information concerning safety, effectiveness, and current use in therapy. 

 Reviews information from a variety of sources, including:

- Peer reviewed journals and databases such as DrugPoints, American Hospital Formulary 

Service Drug Information (AHFS-DI), DrugDex, clinical pharmacology, Medline, national 

guidelines 

- Information from medical professional associations, national commissions, and federal 

government agencies

Using this information, the Committee evaluates the therapeutic effectiveness of new prescription

medications and places them into one of six categories:

 Category 1 – important therapeutic advance

- Provides effective therapy for a disease not adequately treated by any marketed drug, or 

improved effectiveness or safety.

- Products in this category will be included on drug guide (formulary), regardless of cost 

factors.

- Precertification may or may not be recommended.

 Category 2, 2+, 2-

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- Category 2 – therapeutically similar to other available products 

o Clinical differences are not significant, or appear be counterbalanced between products.

- Category 2+ – therapeutically similar to other available products but has clinical advantages 

(clinical efficacy, adverse effects, drug interactions, etc.) to others in the category.

- Category 2- – therapeutically similar to other available products but has clinical 

disadvantages (clinical efficacy, adverse effects, drug interactions, etc.) to others in the 

category.

 Category 3 – not appropriate for drug guide (formulary)

- Has significant disadvantages in safety or efficacy in comparison to other available selfadministered products.

- Products in this category will not be added to drug guide (formulary), regardless of cost 

factors.

 Category 4 - niche products 

- May have an important role for certain patient populations or as second or third-line 

alternatives (sometimes known as “niche” products). 

- At a minimum, these products must be available through precertification or step therapy

for these uses.

We will make a decision to include or not include drugs on the drug guide (formulary) based on these 

categories. For a therapeutically similar drug, we will select drugs based on:

 The six categories (clinical ranking: efficacy/safety)

 Cost of effectiveness of medication

 Other factors (regulations)

A copy of the drug guide (formulary) or information about the availability of a specific drug may be 

requested by calling 1-800-414-2386. The drug guide (formulary) may also be accessed through our 

Internet website at www.aetna.com. The presence of a drug on the drug guide (formulary) does not 

guarantee that you will receive a prescription for that drug from your prescriber for a particular medical 

condition. Precertification, may be necessary for coverage of certain prescription drugs. See the 

Precertification section.

Generic prescription drugs may be substituted by your pharmacist for brand-name prescription drugs. 

Your out-of-pocket costs may be less if you use a generic prescription drug when available.

Prescription drugs covered by this plan are subject to misuse, waste, and/or abuse utilization review by 

us, your provider, and/or your network pharmacy. The outcome of this review may include: limiting 

coverage of the applicable drug(s) to one prescribing provider and/or one network pharmacy, limiting 

the quantity, dosage, day supply, requiring a partial fill or denial of coverage.

What prescription drugs are covered

Your prescriber may give you a prescription in different ways, including:

 Writing out a prescription that you then take to a network pharmacy.

 Calling or e-mailing a network pharmacy to order the medication.

 Submitting your prescription electronically.

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Once you receive a prescription from your prescriber, you may fill the prescription at a network retail, 

mail order or specialty pharmacy.

Retail pharmacy 

Generally, retail pharmacies may be used for up to a 30 day supply of prescription drugs. You should 

show your ID card to the network pharmacy every time you get a prescription filled. The network 

pharmacy will submit your claim. You will pay any cost sharing directly to the network pharmacy.

You do not have to complete or submit claim forms. The network pharmacy will take care of claim 

submission.

See the schedule of benefits below for details on supply limits and cost sharing.

Mail order pharmacy

Generally, the drugs available through mail order are maintenance drugs that you take on a regular basis 

for a chronic or long-term medical condition.

Outpatient prescription drugs are covered when dispensed by a network mail order pharmacy. Each 

prescription is limited to a maximum 90 day supply. Prescriptions for less than a 30 day supply or more 

than a 90 day supply are not eligible for coverage when dispensed by a network mail order pharmacy.

See the schedule of benefits below for details on supply limits and cost sharing.

Specialty pharmacy

Specialty prescription drugs are covered when dispensed through a network retail or specialty 

pharmacy.

Specialty prescription drugs often include typically high-cost drugs that require special handling, special 

storage or monitoring and include but are not limited to oral, topical, inhaled and injected routes of 

administration. You can access the list of specialty prescription drugs by contacting Member Services by 

logging onto your secure member website at www.aetna.com or calling the number on the back of your 

ID card.

All specialty prescription drugs fills after the initial fill must be filled at a network specialty pharmacy 

except for urgent situations.

See the schedule of benefits for details on supply limits and cost sharing.

Other services

Preventive Contraceptives

For females who are able to reproduce, your outpatient prescription drug plan covers certain drugs 

and devices that the U.S. Food and Drug Administration (FDA) has approved to prevent pregnancy 

when prescribed by a prescriber and the prescription is submitted to the pharmacist for 

processing. Your outpatient prescription drug plan also covers related services and supplies needed 

to administer covered devices. At least one form of contraception in each of the methods identified 

by the FDA is included. You can access the list of contraceptive drugs by logging onto your 

secure member website at www.aetna.com or calling the number on your ID card.

We cover over-the-counter (OTC) and generic prescription drugs and devices for each of the 

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methods identified by the FDA at no cost share. If a generic prescription drug or device is not 

available for a certain method, you may obtain certain brand-name prescription drug or device

for that method at no cost share.

Important Note: You may qualify for a medical exception if your provider determines that the 

contraceptives covered standardly as preventive are not medically appropriate. Your prescriber 

may request a medical exception and submit the exception to us.

Diabetic supplies

Eligible health services include but are not limited to the following diabetic supplies upon prescription

by a prescriber:

• Injection devices including insulin syringes, needles and pens

• Test strips - blood glucose, ketone and urine

• Blood glucose calibration liquid

• Lancet devices and kits

• Alcohol swabs

See your medical plan benefits for coverage of blood glucose meters and insulin pumps

Infertility drugs

Eligible health services include oral synthetic ovulation stimulant prescription drugs used primarily for 

the purpose of treating the underlying cause of infertility.

Off-label use

U.S. Food and Drug Administration (FDA) approved prescription drugs may be covered when the offlabel use of the drug has not been approved by the FDA for your symptom(s). Eligibility for coverage is 

subject to the following:

• The drug must be accepted as safe and effective to treat your symptom(s) in one of the 

following standard compendia:

- American Society of Health-System Pharmacists Drug Information (AHFS Drug Information)

- Thomson Micromedex DrugDex System (DrugDex)

- Clinical Pharmacology (Gold Standard, Inc.)

- The National Comprehensive Cancer Network (NCCN) Drug and Biologics Compendium; or

• Use for your symptom(s) has been proven as safe and effective by at least one well-designed 

controlled clinical trial, (i.e., a Phase III or single center controlled trial, also known as Phase II). 

Such a trial must be published in a peer reviewed medical journal known throughout the U.S. 

and either:

- The dosage of a drug for your symptom(s) is equal to the dosage for the same symptom(s) as 

suggested in the FDA-approved labeling or by one of the standard compendia noted above, 

or

- The dosage has been proven to be safe and effective for your symptom(s) by one or more 

well-designed controlled clinical trials. Such a trial must be published in a peer reviewed 

medical journal.

Health care services related to off-label use of these drugs may be subject to precertification, step 

therapy or other requirements or limitations.

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Orally administered anti-cancer drugs, including chemotherapy drugs

Eligible health services include any drug prescribed for the treatment of cancer if it is recognized for 

treatment of that indication in a standard reference compendium or recommended in the medical 

literature even if the drug is not approved by the FDA for a particular indication.

Pain management for the terminally ill

Eligible health services include pain management outpatient prescription drugs for a terminally ill 

covered person

Pediatric asthma services and supplies

Eligible health services include outpatient self-management training, education and the following 

supplies for a child:

 Nebulizers, including face masks and tubing

 Inhaler spacers

 Peak flow meters

Preventive care drugs and supplements

Eligible health services include preventive care drugs and supplements (including over-the-counter 

drugs and supplements) as required by the ACA guidelines when prescribed by a prescriber and the 

prescription is submitted to the pharmacist for processing.

Risk reducing breast cancer prescription drugs

Eligible health services include prescription drugs when prescribed by a prescriber and the prescription

is submitted to the pharmacist for processing for a woman who is at:

• Increased risk for breast cancer, and

• Low risk for adverse medication side effects

Sexual dysfunction/enhancement

Eligible health services include prescription drugs for the treatment of sexual 

dysfunction/enhancement. 

For the most up-to-date information on dosing, call the toll-free number on your ID card.

Tobacco cessation prescription and over-the-counter drugs

Eligible health services include FDA-approved prescription drugs and over-the-counter (OTC) drugs to 

help stop the use of tobacco products, when prescribed by a prescriber and the prescription is 

submitted to the pharmacist for processing.

How you get an emergency prescription filled

You may not have access to a network pharmacy in an emergency or urgent care situation, or you may 

be traveling outside of the plan’s service area. If you must fill a prescription in either situation, we will 

reimburse you as shown in the table below.

Type of pharmacy Your cost share

Network pharmacy and out-of-area network 

pharmacy

• You pay the copayment.

Out-of-network pharmacy • You pay the pharmacy directly for the cost 

 of the prescription. Then you fill out and 

 send a prescription drug refund form to 

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 us, including all itemized pharmacy

 receipts.

• Coverage is limited to items obtained in 

 connection with covered emergency and 

 out-of-area urgent care services.

• You must access a network pharmacy for 

 urgent care prescriptions inside the 

 service area.

• Submission of a claim doesn’t guarantee 

 payment. If your claim is approved, you 

 will be reimbursed the cost of your 

 prescription less your copayment/ 

 coinsurance.

Where your schedule of benefits fits in

You are responsible for paying your part of the cost sharing. The schedule of benefits below shows any 

benefit limitations and any out-of-pocket costs you are responsible for. Keep in mind that you are 

responsible for costs not covered under this plan.

Your prescription drug costs are based on:

 The type of prescription you use, (generic, brand-name, biosimilar, preferred, non-preferred,

specialty, injectable, and self-injectable prescription drugs).

 Where you fill your prescription, (at a network retail, mail order or specialty pharmacy).

Let us help you understand how the cost sharing works.

How your copayment/coinsurance works

Your copayment/coinsurance is the amount you pay for each prescription fill or refill. Your schedule of 

benefits shows you which copayments/coinsurance you need to pay for specific prescription fill or refill. 

You will pay any cost sharing directly to the network pharmacy.

How your outpatient prescription drug maximum out-of-pocket limit works

You will pay your outpatient prescription drug copayments/coinsurance up to the outpatient

prescription drug maximum out-of-pocket limit for your plan.

Your schedule of benefits shows the outpatient prescription drug maximum out-of-pocket limits that 

apply to your plan. Once you reach your outpatient prescription drug maximum out-of-pocket limit, 

your plan will pay for outpatient prescription drug covered benefits for the remainder of that calendar 

year.

What precertification requirements apply

Why do some drugs need precertification?

For certain drugs, your prescriber or your pharmacist needs to get approval from us before we will cover 

the drug. This is called “precertification.” The requirement for getting approval in advance guides

appropriate use of precertified drugs and makes sure they are medically necessary. For the most up-todate information, call the toll-free number on your member ID card or log on to your secure member 

website at www.aetna.com.

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There is another type of precertification for prescription drugs and that is step therapy. Step therapy is 

a type of precertification where we require you to first try certain drugs to treat your medical condition 

before we will cover another drug for that condition. 

You will find the step therapy prescription drugs on the drug guide. For the most up-to-date 

information, call the toll-free Member Services number on your member ID card or log on to your secure 

member website at www.aetna.com.

The chart below shows the different types of precertification requests and how much time we have to 

tell you about our decision. 

Type of request Standard (non-urgent) Exigent circumstances

Initial decision by us 72 hours As soon as possible, but no 

longer than 24 hours

If we need more information, we 

will notify you within

Not applicable 24 hours

Once we have more information, 

our decision will be made

Not applicable 24 hours

How long the drug will be 

covered if request is approved

As long as it is prescribed, 

including refills

As long as it is prescribed, 

including refills

A request under exigent circumstances can be made when:

 Your condition may seriously affect your life, health, or ability to get back maximum function

 You are going through a current course of treatment using a non-preferred drug

What if my precertification request is denied? 

If precertification request of a non-preferred drug and/or step therapy exception request, you can file a 

grievance seeking an external exception review. For more information see the When you disagree –

claim decisions and appeals procedures section in the EOC. 

Sometimes you or your prescriber may seek a medical exception to get health care services for drugs 

not listed on the drug guide or for brand-name, specialty or biosimilar prescription drugs or for which 

health care services are denied through precertification, step therapy. You or your prescriber can 

contact us and will need to provide us with the required clinical documentation. Any waiver granted as a 

result of a medical exception shall be based upon an individual, case by case determination, and will not 

apply or extend to other covered persons. If approved by us, you will receive the preferred drug benefit 

level. See the schedule of benefits below for details on cost sharing.

Prescribing units

Some prescription drugs are subject to quantity limits. These quantity limits help your prescriber and 

pharmacist check that your prescription drug is used correctly and safely. We rely on medical guidelines, 

FDA-approved recommendations and other criteria developed by us to set these quantity limits.

Any prescription drug that has duration of action extending beyond one (1) month shall require the 

number of copayments per prescribing unit that is equal to the anticipated duration of the 

medication. For example, a single injection of a drug that is effective for three (3) months would require 

three (3) copayments.

Specialty prescription drugs are limited to no more than a 30 day supply.

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What your plan doesn’t cover – some eligible health service exceptions

In this section we tell you about the exceptions. These prescription drug exceptions are in 

addition to the exceptions listed in the EOC. If you receive any services listed in this section or in 

the EOC, they will not be covered.

Allergy sera and extracts administered via injection

Any services related to the dispensing, injection or application of a drug, except as specifically 

provided in the Eligible health services under your plan – Physicians and other health professionals 

section.

Biological sera 

Cosmetic drugs

 Medications or preparations used for cosmetic purposes. 

Devices, products and appliances, except those that are specifically covered

Dietary supplements including medical foods except as specifically provided in the Eligible health 

services under your plan – Other services section

Drugs or medications

 Administered or entirely consumed at the time and place it is prescribed or dispensed. except as 

medically necessary to treat withdrawal symptoms as part of ambulatory detoxification

 Which do not, by federal or state law, require a prescription order (i.e. over-the-counter (OTC) 

drugs), even if a prescription is written. See the Eligible health services under your plan –

Outpatient section.

 That includes the same active ingredient or a modified version of an active ingredient.

 That is therapeutically equivalent or therapeutically alternative to a covered prescription drug

(unless a medical exception is approved)

 That is therapeutically equivalent or therapeutically alternative to an over-the-counter (OTC) 

product (unless a medical exception is approved).

 Not approved by the FDA or not proven safe and effective

 Provided under your medical plan or while an inpatient of a healthcare facility

 That include methadone maintenance medications used for drug detoxification

 That includes vitamins and minerals unless recommended by the United States Preventive 

Services Task Force (USPSTF)

 For which the cost is covered by a federal, state, or government agency (for example: Medicaid 

or Veterans Administration)

 That are drugs or growth hormones used to stimulate growth and treat idiopathic short stature 

unless there is evidence that the member meets one or more clinical criteria detailed in our 

precertification and clinical policies.

Duplicative drug therapy (e.g. two antihistamine drugs)

Genetic care

• Any treatment, device, drug, service or supply to alter the body’s genes, genetic make-

 up, or the expression of the body’s genes except for the correction of congenital birth 

 defects.

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Immunizations related to travel or work

Immunization or immunological agents

Infertility

 Injectable prescription drugs used primarily for the treatment of infertility.

Injectables:

• Any charges for the administration or injection of prescription drugs or injectable insulin and 

other injectable drugs covered by us except as specifically provided in the Eligible health services 

under your plan – Physicians and other health professionals section.

• Needles and syringes, except for those used for self-administration of an injectable drug

• For any drug, which due to its characteristics as determined by us must typically be 

administered or supervised by a qualified provider or licensed certified health professional in an 

outpatient setting. This exception does not apply to Depo Provera and other injectable drugs 

used for contraception

Insulin pumps or tubing or other ancillary equipment and supplies for insulin pumps see the 

Eligible health services under your plan – Diabetic equipment, supplies and education section.

Prescription drugs:

 Dispensed by other than a network retail, mail order and specialty pharmacies

 Dispensed by an out-of-network mail order pharmacy, except in a medical emergency or urgent 

care situation.

 For which there is an over-the-counter (OTC) product which has the same active ingredient and 

strength even if a prescription is written.

 Packaged in unit dose form.

 Filled prior to the effective date or after the termination date of coverage under this rider.

 Dispensed by a mail order pharmacy that includes prescription drugs that cannot be shipped by 

mail due to state or federal laws or regulations, or when the plan considers shipment through 

the mail to be unsafe. Examples of these types of drugs include, but are not limited to, narcotics, 

amphetamines, DEA controlled substances and anticoagulants.

 That include an active metabolite, stereoisomer, prodrug (precursor) or altered formulation of 

another drug and is no clinically superior to that drug as determined by the plan.

 That are ordered by a dentist or prescribed by an oral surgeon in relation to the removal of 

teeth, or prescription drugs for the treatment of a dental condition. 

 That are considered oral dental preparations and fluoride rinses, except pediatric fluoride 

tablets or drops as specified on the preferred drug guide. 

 That are non-preferred drugs, unless non-preferred drugs are specifically covered as described 

in your schedule of benefits. However, a non-preferred drug will be covered if in the judgment 

of the prescriber there is no equivalent prescription drug on the preferred drug guide or the 

product on the preferred drug guide is ineffective in treating your disease or condition or has 

caused or is likely to cause an adverse reaction or harm you.

 That are not considered covered or related to a non-covered service.

 That are being used or abused in a manner that is determined to be furthering an addiction to a 

habit-forming substance, the use of or intended use of which would be illegal, unethical, 

imprudent, abusive, not medically necessary, or otherwise improper; and drugs obtained for 

use by anyone other than the member identified on the ID card.

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Refills

 Refills dispensed more than one year from the date the latest prescription order was written, or 

as otherwise permitted by applicable law of the jurisdiction in which the drug is dispensed. 

Replacement of lost or stolen prescriptions

Test agents except diabetic test agents

Schedule of benefits

How you share the cost of your outpatient prescription drugs

This schedule of benefits lists the copayments/coinsurance, if any, that apply to the services you 

receive under this plan. You should review this schedule to become familiar with your 

copayments/coinsurance and any limits that apply to the services.

How to read your schedule of benefits

 When we say:

- “In-network coverage”, we mean you get care from network providers.

 You are responsible to pay any copayments/coinsurance.

 You are responsible for full payment of any health care services you receive that are not a 

covered benefit.

 This plan has maximums for specific covered benefits. For example, these could be supply limit 

maximums.

Important note:

All covered benefits are subject to the calendar year copayment/coinsurance unless otherwise 

noted in the schedule of benefits below.

Plan features Copayment/Coinsurance Maximums

Outpatient prescription drug maximum out-of-pocket limit

Outpatient prescription drug maximum out-of-pocket limit per calendar year

Individual $3,500 per calendar year

Family $7,000 per calendar year

Eligible health services In-network coverage

Preferred generic prescription drugs

Per prescription copayment/coinsurance

For each fill up to a 30

day supply filled at a retail pharmacy

$10 copayment per supply 

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More than a 31

day supply but less than a 91 day supply filled at a 

mail order pharmacy

$20 copayment per supply

Non-preferred generic prescription drugs

Per prescription copayment/coinsurance

For each fill up to a 30 day supply filled at a retail 

pharmacy

$50 copayment per supply 

More than a 31 day supply but less than a 91 day 

supply filled at a mail order pharmacy

$100 copayment per supply

Preferred brand-name prescription drugs

Per prescription copayment/coinsurance

For each fill up to a 30 day supply filled at a retail 

pharmacy

$30 copayment per supply 

More than a 31 day supply but less than a 91 day 

supply filled at a mail order pharmacy

$60 copayment per supply

Non-preferred brand-name prescription drugs

Per prescription copayment/coinsurance

For each fill up to a 30 day supply filled at a retail 

pharmacy

$50 copayment per supply 

More than a 31 day supply but less than a 91 day 

supply filled at a mail order pharmacy

$100 copayment per supply

Diabetic supplies and insulin

Per prescription copayment/coinsurance

For each fill up to a 30 day supply filled at a retail 

pharmacy

Paid according to the type of drug per the 

schedule of benefits, above

More than a 31 day supply but less than a 91 day 

supply filled at a mail order pharmacy

Paid according to the type of drug per the 

schedule of benefits, above

Orally administered anti-cancer prescription drugs including specialty 

prescription drugs

Per prescription copayment/coinsurance

For each fill up to a 30 day supply filled at a retail $0 copayment per supply 

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pharmacy

More than a 31 day supply but less than 91 supply 

filled at a mail order pharmacy

$0 copayment per supply 

Pediatric asthma services and supplies

Per prescription copayment/coinsurance

For each 30 day supply Paid according to the type of drug per the 

schedule of benefits, above

Specialty prescription drugs

Per prescription copayment/coinsurance

For each fill up to a 30 day supply filled at a retail 

pharmacy

Coinsurance per supply is 20% (of the Plan's 

cost) but will be no more than $200

Preventive care drugs and supplements

Preventive care drugs and supplements filled at a 

pharmacy For each 30 day supply

$0

Maximums: Coverage will be subject to any sex, age, 

medical condition, family history, and 

frequency guidelines in the recommendations 

of the United States Preventive Services Task 

Force. For details on the guidelines and the 

current list of covered preventive care drugs 

and supplements, contact Member Services by 

logging onto your secure member website at 

www.aetna.com or calling the number on the 

back of your ID card.

Risk reducing breast cancer prescription drugs

Risk reducing breast cancer prescription drugs

filled at a pharmacy For each 30 day supply

$0

Maximums: Coverage will be subject to any sex, age, 

medical condition, family history, and 

frequency guidelines in the recommendations 

of the United States Preventive Services Task 

Force. For details on the guidelines and the 

current list of covered risk reducing breast 

cancer prescription drugs, contact Member 

Services by logging onto your secure member 

website at www.aetna.com or calling the 

number on the back of your ID card.

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HI Rider00060 04 14 CA

If a prescriber prescribes a covered brand-name prescription drug where a generic prescription 

drug equivalent is available and specifies “Dispense As Written” (DAW), you will pay the cost sharing 

for the brand-name prescription drug. If a prescriber does not specify DAW and you request a 

covered brand-name prescription drug where a generic prescription drug equivalent is available 

you will be responsible for the cost difference between the brand-name prescription drug and the 

generic prescription drug equivalent, and the cost sharing that applies to brand-name prescription 

drugs. The DAW charge is not applied towards your calendar year prescription drug maximum outof-pocket limit.

Tobacco cessation prescription and over-the-counter drugs

Tobacco cessation prescription drugs and OTC 

drugs filled at a pharmacy For each 90 day supply

$0 per prescription or refill

Maximums:

Coverage is permitted for two 90-day treatment 

regimens only. Any additional treatment regimens 

will be subject to the cost sharing in your 

schedule of benefits 

Coverage will be subject to any sex, age, 

medical condition, family history, and 

frequency guidelines in the recommendations 

of the United States Preventive Services Task 

Force. For details on the guidelines and the 

current list of covered tobacco cessation 

prescription drugs and OTC drugs, contact 

Member Services by logging onto your secure 

member website at www.aetna.com or calling 

the number on the back of your ID card.

General coverage provisions

This section provides detailed explanations about the:

 Outpatient prescription drug maximum out-of-pocket limits

Outpatient prescription drug maximum out-of-pocket limits provisions

Eligible health services that are subject to the maximum out-of-pocket limit include eligible health 

services provided under the medical plan and the outpatient prescription drug plan rider.

The outpatient prescription drug maximum out-of-pocket limit is the maximum amount you are 

responsible to pay for copayments/coinsurance for eligible health services during the calendar 

year. This plan has an individual and family outpatient prescription drug maximum out-of-pocket 

limit. 

Individual

Once the amount of the copayments/coinsurance you and your covered dependents have paid for 

eligible health services during the calendar year meets the individual outpatient prescription drug

maximum out-of-pocket limit, this plan will pay 100% of the covered benefits that apply toward the 

limit for the rest of the calendar year for that person.

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Family

Once the amount of the copayments/coinsurance you and your covered dependents have paid for 

eligible health services during the calendar year meets this family outpatient prescription drug

maximum out-of-pocket limit, this plan will pay 100% of such covered benefits that apply toward 

the limit for the remainder of the calendar year for all covered family members.

To satisfy this family outpatient prescription drug maximum out-of-pocket limit for the rest of the 

calendar year the following must happen:

• The family outpatient prescription drug maximum out-of-pocket limit is a cumulative 

outpatient prescription drug maximum out-of-pocket limit for all family members. The 

family maximum out-of-pocket limit can be met by a combination of family members with 

no single individual within the family contributing more than the individual outpatient 

prescription drug maximum out-of-pocket limit amount in a calendar year.

The maximum out-of-pocket limit is the maximum amount you are responsible to pay for 

copayment/coinsurance for eligible health services during the calendar year. This plan has an 

individual and family outpatient prescription drug maximum out-of-pocket limit.

Costs that you incur that do not apply to your outpatient prescription drug maximum out-of-pocket 

limit.

Certain costs that you incur do not apply toward the outpatient prescription drug maximum out-ofpocket limit. These include:

 All costs for non-covered services

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HI HSOB 03 CA 10 GE-02

1

Aetna Health of California Inc.

Health Maintenance Organization (HMO)

Schedule of benefits

If this is an ERISA plan, you have certain rights under this plan. Please contact the 

contract holder for additional information.

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2

Schedule of benefits 

This schedule of benefits lists the copayments/coinsurance, if any, that apply to the services you receive 

under this plan. You should review this schedule to become familiar with your copayments/coinsurance

and any limits that apply to the services.

How to read your schedule of benefits

 When we say “in-network coverage”, we mean you get care from network providers.

 The copayments/coinsurance listed in the schedule of benefits below reflects your 

copayment/coinsurance amounts. 

 You are responsible to pay any copayments/coinsurance.

 The coinsurance listed in the schedule of benefits reflects the plan coinsurance percentage. This 

is the coinsurance amount the member pays. The plan is responsible for paying any remaining 

coinsurance.

 You are responsible for full payment of any health care services you receive that are not a 

covered benefit.

 This plan has maximums for specific covered benefits. For example, these could be visit, day or 

dollar maximums.

 At the end of this schedule you will find detailed explanations about your:

- Maximum out-of-pocket limits

- Maximums

Important note:

All covered benefits are subject to the calendar year copayment/coinsurance unless otherwise 

noted in the schedule of benefits below.

We are here to answer any questions. Contact Member Services by logging onto your secure member 

website at www.Aetna.com or at the toll-free number on your ID card.

The coverage described in this schedule of benefits will be provided under Aetna Health of California 

Inc.’s HMO agreement. This schedule of benefits replaces any schedule of benefits previously in effect 

under the HMO agreement. Keep this schedule of benefits with your EOC.

Plan features Maximums

In-network coverage*

Maximum out-of-pocket limit

Maximum out-of-pocket limit per calendar year

Individual $3,500 per calendar year

Family $7,000 per calendar year

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Eligible health services In-network coverage*

1. Preventive care and wellness

Routine physical exams

Performed at a physician’s, PCP office $0 per visit

No deductible applies

Covered persons through age 22:

Maximum age and visit limits per 12 months

Subject to any age and visit limits provided for 

in the comprehensive guidelines supported by 

the American Academy of Pediatrics/Bright 

Futures/Health Resources and Services 

Administration guidelines for children and 

adolescents.

For details, contact your physician or Member 

Services by logging onto your secure member 

website at www.aetna.com or calling the 

number on the back of your ID card.

Covered persons age 22 and over:

Maximum visits per 12 months

1 visit

Preventive care immunizations

Performed in a facility or at a physician's office $0 per visit

No deductible applies

Limited to:

Covered persons through age 22

Covered persons age 22 and over but less than 65

Covered persons age 65 and over

Subject to any age limits provided for in the 

comprehensive guidelines supported by 

Advisory Committee on Immunization Practices 

of the Centers for Disease Control and 

Prevention

For details, contact your physician or Member 

Services by logging onto your secure member 

website at www.aetna.com or calling the 

number on the back of your ID card.

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Well woman preventive visits

routine gynecological exams (including pap smears)

Performed at a physician’s, PCP, obstetrician 

(OB), gynecologist (GYN) or OB/GYN office

$0 per visit

No deductible applies

Maximums Subject to any age limits provided for in the 

comprehensive guidelines supported by the 

Health Resources and Services Administration.

Maximum visits per 365 Days 1 visit(s)

Preventive screening and counseling services

Office visits

 Obesity and/or healthy diet counseling

 Misuse of alcohol and/or drugs

 Use of tobacco products

 Sexually transmitted infection counseling

 Genetic risk counseling for breast and 

ovarian cancer

$0 per visit

$0 per visit

$0 per visit

$0 per visit

$0 per visit

No deductible applies

Obesity and/or healthy diet counseling maximums:

Maximum visits per day

(This maximum applies only to covered persons 

age 22 and older.)

1 visit*

Maximum visits per calendar year

(This maximum applies only to covered persons 

age 22 and older.)

26 visits (however, of these only 10 visits will 

be allowed under the plan for healthy diet 

counseling provided in connection with 

Hyperlipidemia (high cholesterol) and other 

known risk factors for cardiovascular and dietrelated chronic disease)*

*Note: In figuring the maximum visits, each session of up to 60 minutes is equal to one visit.

Misuse of alcohol and/or drugs maximums:

Maximum visits per day 1 visit*

Maximum visits per calendar year 5 visits*

*Note: In figuring the maximum visits, each session of up to 60 minutes is equal to one visit.

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Use of tobacco products maximums:

Maximum visits per day 1 visit*

Maximum visits per calendar year 8 visits*

*Note: In figuring the maximum visits, each session of up to 60 minutes is equal to one visit.

Sexually transmitted infection counseling maximums:

Maximum visits per calendar year 2 visits*

*Note: In figuring the maximum visits, each session of up to 60 minutes is equal to one visit.

Genetic risk counseling for breast and ovarian cancer maximums:

Genetic risk counseling for breast and ovarian 

cancer

Not subject to any age or frequency limitations

Routine cancer screenings

(applies whether performed at a physician’s, PCP, specialist office or facility)

Routine cancer screenings $0 per visit

Maximums Subject to any age; family history; and 

frequency guidelines as set forth in the most 

current:

• Evidence-based items that have in effect a 

rating of A or B in the current 

recommendations of the United States 

Preventive Services Task Force; and

• The comprehensive guidelines supported 

by the Health Resources and Services 

Administration.

For details, contact your physician or Member 

Services by logging onto your secure member 

website at www.aetna.com or calling the 

number on your ID card.

No deductible applies

Lung cancer screening maximum 1 screening(s) every 12 month(s)*

Important note:

Any lung cancer screenings that exceed the lung cancer screening maximum above are covered 

under the Outpatient diagnostic testing section.

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Prenatal care

Prenatal care services (provided by an obstetrician (OB), gynecologist (GYN), 

and/or OB/GYN)

Preventive care services only $0 per visit

No deductible applies

Comprehensive lactation support and counseling services 

Lactation counseling services - facility or office 

visits

$0 per visit

No deductible applies

Lactation counseling services maximum visits per 

calendar year either in a group or individual 

setting

6 visits*

Important note:

Any visits that exceed the lactation counseling services maximum are covered under physician

services office visits.

Breast feeding durable medical equipment 

Breast pump supplies and accessories $0 per item

No deductible applies

Important note:

See the Breast feeding durable medical equipment section of the certificate for limitations on breast 

pump and supplies.

Family planning services – female contraceptives 

Female contraceptive counseling services

office visit

$0 per visit

No deductible applies

Counseling services

Contraceptive counseling services maximum visits 

per calendar year either in a group or individual 

setting

2 visit(s)*

Important note:

Any visits that exceed the contraceptive counseling services maximum are covered under Physician

services office visits.

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Devices

Female contraceptive device provided, 

administered, or removed, by a physician during 

an office visit

$0 per visit

No deductible applies

Female voluntary sterilization

Inpatient $0 per visit

No deductible applies

Outpatient $0 per visit

No deductible applies

Eligible health services In-network coverage*

2. Physicians and other health professionals

Physicians and specialists office visits (non-surgical)

Physician services

Office hours visits (non-surgical) non preventive 

care

$45 per visit

No deductible applies

Telemedicine consultation by a physician, PCP $45 per visit

No deductible applies

Telemedicine consultation by a specialist $65 per visit

No deductible applies

Allergy injections

Performed at a physician’s, PCP or specialist

office when you see the physician

Covered according to the type of benefit and 

the place where the service is received.

Allergy testing and treatment

Performed at a physician’s, PCP or specialist

office

Covered according to the type of benefit and 

the place where the service is received.

Immunizations when not part of the physical exam

Immunizations when not part of the physical 

exam 

Covered according to the type of benefit and 

the place where the service is received.

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No deductible applies

Injectable medications 

Performed at a physician’s, PCP or specialist

office

Covered according to the type of benefit and 

the place where the service is received.

No deductible applies

Specialist office visits 

Office hours visit (non-surgical) $65 per visit

No deductible applies

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Eligible health services In-network coverage*

3. Hospital and other facility care

Hospital care

Inpatient hospital

(room and board)

$2,000 per admission

No deductible applies

Anesthesia and hospital charges for dental care

Anesthesia and hospital charges for dental care Covered according to the type of benefit and 

the place where the service is received

Alternatives to hospital stays

Outpatient surgery and physician surgical services

$500 per visit 

No deductible applies

Performed at a physician, PCP or specialist office Covered according to the type of benefit and 

the place where the service is received.

No deductible applies

Home health care 

Outpatient $65 per visit

No deductible applies

Maximum visits per calendar year 120 visits

Limited to: 3 intermittent visit(s) per day 

provided by a participating home health care 

agency; 1 visit equals a period of 4 hours or 

less. Intermittent visits are considered periodic 

and recurring visits that skilled nurses make to 

ensure your proper care 

The intermittent requirement may be waived 

to allow coverage for up to 12 hours with a 

daily maximum of (3 visits). 

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Hospice care

Inpatient facility 

(room and board)

$2,000 per admission 

No deductible applies

Hospice care

Outpatient $65 per visit 

No deductible applies

Skilled nursing facility

Inpatient facility

(room and board)

$2,000 per admission

No deductible applies

Eligible health services In-network coverage*

4. Emergency services and urgent care

Emergency services

Hospital emergency room $150 per visit

No deductible applies

Non-emergency care in a hospital emergency 

room 

Not covered

Important note:

 As out-of-network providers do not have a contract with us. The provider may not accept 

payment of your cost share, (deductible, copayment and coinsurance), as payment in full. 

You may receive a bill for the difference between the amount billed by the provider and the 

amount paid by this plan. If the provider bills you for an amount above your cost share, you 

are not responsible for paying that amount. You should send the bill to the address listed on 

the back of your ID card, and we will resolve any payment dispute with the provider over 

that amount. Make sure the member's ID number is on the bill.

 A separate hospital emergency room deductible or copayment/coinsurance will apply for 

each visit to an emergency room. If you are admitted to a hospital as an inpatient right after 

a visit to an emergency room, your emergency room copayment/coinsurance will be waived 

and your inpatient copayment/coinsurance will apply.

Urgent care

Urgent medical care 

(at a non-hospital free standing facility)

$35 per visit

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No deductible applies

Non-urgent use of urgent care provider

(at a non-hospital free standing facility)

Not covered 

A separate urgent care deductible or copayment/coinsurance will apply for each visit to an urgent 

care provider

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Eligible health services In-network coverage*

5. Specific conditions

Diabetic equipment, supplies and education

Diabetic equipment, supplies and education $45 per visit

No deductible applies

Family planning services - other

Voluntary Sterilization for males

Outpatient Covered according to the type of benefit and 

the place where the service is received.

Gender reassignment

Performed at inpatient hospital $2,000 per admission

No deductible applies

Performed in a hospital outpatient facility $500 per visit 

No deductible applies

Performed in a facility other than a hospital

outpatient facility

$500 per visit 

No deductible applies

Maternity and related newborn care

Inpatient

(room and board)

$2,000 per admission

No deductible applies

Any copayment that is collected applies to the delivery and postpartum care services provided by an 

OB, GYN, or OB/GYN only. No copayment that is collected applies to prenatal care services provided 

by an OB, GYN, or OB/GYN.

See the Prenatal care section for cost-sharing and maximums that apply to these services.

Delivery services and postpartum care services

Performed in a facility or at a physician's office $45 per visit

No deductible applies

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Other prenatal care services Covered according to the type of benefit and 

the place where the service is received

Mental health treatment

Coverage is provided under the same terms, conditions as any other illness.

Mental health treatment - inpatient

Inpatient mental health treatment 

during a hospital confinement

(room and board)

$2,000 per admission

No deductible applies

Other inpatient mental health treatment services 

and supplies 

during a hospital confinement

(other than room and board)

$2,000 per admission

No deductible applies

Residential treatment - inpatient

Inpatient residential treatment facility 

during a hospital confinement

(room and board)

$2,000 per admission

No deductible applies

Mental health treatment - outpatient

Outpatient mental health treatment office visits

to a physician or behavioral health provider (and 

telemedicine consultation*)

$65 per visit

No deductible applies

Outpatient – all other services (as described in 

your EOC)

$0 per visit

No deductible applies

*Your plan covers telemedicine only when you get your telephone or internet-based consult 

through an authorized internet service vendor who conducts telemedicine consultations that has 

contracted with Aetna to offer these services. DocFind® tells you who those are.

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Substance related disorders treatment 

Coverage is provided under the same terms, conditions as any other illness.

Detoxification - inpatient

Inpatient substance abuse detoxification

during a hospital confinement

(room and board)

$2,000 per admission

No deductible applies

Substance related disorders treatment - outpatient

Outpatient substance abuse office visits to a 

physician or behavioral health provider

$65 per visit

No deductible applies

Rehabilitation - inpatient

Inpatient substance abuse rehabilitation

during a hospital confinement

(room and board)

$2,000 per admission

No deductible applies

Residential treatment - rehabilitation

Inpatient residential treatment facility 

during a hospital confinement

(room and board)

$2,000 per admission

No deductible applies

Residential treatment - rehabilitation

Other Inpatient residential treatment facility 

services and supplies

during a hospital confinement

(other than room and board

$2,000 per admission

No deductible applies

Outpatient – all other services (as described in 

your EOC)

$0 per visit

No deductible applies

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Reconstructive breast surgery 

Reconstructive breast surgery Covered according to the type of benefit and 

the place where the service is received.

No deductible applies

Reconstructive surgery and supplies

Reconstructive surgery and supplies Covered according to the type of benefit and 

the place where the service is received.

No deductible applies

Eligible health services Network (IOE facility) Network (Non-IOE 

facility)

Transplant services facility and non-facility

Inpatient hospital transplant 

services (room and board)

$2,000 per admission Not covered

No deductible applies Not covered

Outpatient 

$500 per transplant Not covered

No deductible applies

Physician services including 

office visits

Covered according to the type 

of benefit and the place where 

the service is received.

Not covered

Eligible health services In-network coverage*

Treatment of basic infertility

Basic infertility Covered according to the type of benefit and 

the place where the service is received

Eligible health services In-network coverage*

6. Specific therapies and tests

Outpatient diagnostic testing

Diagnostic complex imaging services

Performed in the hospital outpatient department 

of a hospital

$150 per visit

No deductible applies

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Performed at an outpatient facility other than the 

hospital outpatient department of a hospital

$150 per visit

No deductible applies

Diagnostic lab work

Performed in the hospital outpatient department 

of a hospital

$0 per visit

No deductible applies

Performed at an outpatient facility other than the 

hospital outpatient department of a hospital

$0 per visit

No deductible applies

Diagnostic radiological services

Performed in the hospital outpatient department 

of a hospital

$0 per visit

No deductible applies

Performed at an outpatient facility other than the 

hospital outpatient department of a hospital

$0 per visit

No deductible applies

Chemotherapy

Chemotherapy Covered according to the type of benefit and the 

place where the service is received.

No deductible applies

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Outpatient infusion therapy 

Performed in a physician’s office Covered according to the type of benefit and 

the place where the service is received.

Performed at a preferred infusion location Covered according to the type of benefit and 

the place where the service is received.

Performed in a person’s home Covered according to the type of benefit and 

the place where the service is received.

Performed in the outpatient department of a 

hospital

Covered according to the type of benefit and 

the place where the service is received.

Performed at an outpatient facility other than the 

outpatient department of a hospital

Covered according to the type of benefit and 

the place where the service is received.

Specialty prescription drugs

Performed in a physician’s office Covered according to the type of benefit and the 

place where the service is received.

Performed at a preferred infusion location Covered according to the type of benefit and the 

place where the service is received.

Performed in a person’s home Covered according to the type of benefit and the 

place where the service is received.

Performed in the outpatient department of a 

hospital

Covered according to the type of benefit and the 

place where the service is received.

Performed at an outpatient facility other than the 

outpatient department of a hospital

Covered according to the type of benefit and the 

place where the service is received.

Outpatient radiation therapy

Radiation therapy Covered according to the type of benefit and 

the place where the service is received.

Short-term cardiac and pulmonary rehabilitation services

Cardiac rehabilitation

Cardiac rehabilitation $65 per visit

No deductible applies

Pulmonary rehabilitation

Pulmonary rehabilitation $65 per visit

No deductible applies

Outpatient cognitive rehabilitation 

Outpatient cognitive rehabilitation Covered according to the type of benefit and 

the place where the service is received.

Outpatient physical and occupational therapies

$65 per visit

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No deductible applies

Outpatient speech therapy 

Outpatient speech therapy $65 per visit

No deductible applies

Habilitation therapy services

Therapies other than physical, occupational, and 

speech 

Covered according to the type of benefit and 

the place where the service is received

Outpatient physical and occupational therapies

$65 per visit

No deductible applies

Outpatient speech therapy

Outpatient Speech therapy $65 per visit

No deductible applies

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Eligible health services In-network coverage*

7. Other services

Acupuncture

Acupuncture $15 per visit

No deductible applies

Maximum visits per calendar year 20 visits

Ambulance service

Ground ambulance $150 per trip

No deductible applies

Air or water ambulance $150 per trip

No deductible applies

Clinical trial therapies (experimental or investigational)

Clinical trial therapies Covered according to the type of benefit and 

the place where the service is received.

Clinical trials (routine patient costs)

Clinical trial (routine patient costs) Covered according to the type of benefit and 

the place where the service is received.

Durable medical equipment (DME)

DME $45 per item

No deductible applies

Hearing exams

Routine hearing exams

Covered persons through age 16

$0 per visit

No deductible applies

Nutritional supplements

Nutritional supplements $45 per item

No deductible applies

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Obesity (bariatric) surgery

Obesity (bariatric) surgery Covered according to the type of benefit and 

the place where the service is received.

Orthotic devices

Orthotic devices $0 per item

No deductible applies

Osteoporosis

Physician’s office visits $65 per visit

No deductible applies

Prosthetic devices

Prosthetic devices $0 per item

No deductible applies

Spinal manipulation

Spinal manipulation $15 per visit

No deductible applies

Maximum visits per calendar year 20 visits

Vision care

Pediatric vision care

Routine vision exams (including refraction)

Performed by a legally qualified ophthalmologist 

or optometrist

$0 per visit

No deductible applies

Maximum visits per 24 months 1 visit(s)

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Adult vision care

Limited to covered person age 19 and over

Routine vision exams (including refraction)

Performed by a legally qualified ophthalmologist 

or optometrist

$0 per visit

No deductible applies

Maximum visits per 24 months 1 visit(s)

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General coverage provisions

This section provides detailed explanations about the:

 Maximum out-of-pocket limits

 Maximums

that are listed in the first part of this schedule of benefits.

Copayments

Copayment

This is a specified dollar amount or percentage that must be paid by you at the time you receive 

eligible health services from a network provider. If Aetna compensates network providers on the 

basis of the reasonable amount, your cost share is based on this amount.

Per admission copayment

A per admission copayment is an amount you are required to pay when you or a covered dependent

have a stay in an inpatient facility.

Coinsurance

The specific percentage you have to pay for a health care service listed in the schedule of benefits.

Maximum out-of-pocket limits provisions 

Eligible health services that are subject to the maximum out-of-pocket limit include prescription 

drug eligible health services provided under the medical plan and the outpatient prescription drug 

plan rider.

Individual

Once the amount of the copayments/coinsurance you or your covered dependents have paid for 

eligible health services during the calendar year meets the individual maximum out-of-pocket 

limit, this plan will pay 100% of the covered benefits that apply toward the limit for the rest of the 

calendar year for that person.

Family

Once the amount of the copayments/coinsurance you or your covered dependents have paid for 

eligible health services during the calendar year meets this family maximum out-of-pocket limit, 

this plan will pay 100% of such covered benefits that apply toward the limit for the remainder of the 

calendar year for all covered family members.

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To satisfy this family maximum out-of-pocket limit for the rest of the calendar year, the following 

must happen:

 The family maximum out-of-pocket limit is a cumulative maximum out-of-pocket limit for 

all family members. The family maximum out-of-pocket limit can be met by a combination 

of family members with no single individual within the family contributing more than the 

individual maximum out-of-pocket limit amount in a calendar year.

The maximum out-of-pocket limit is the maximum amount you are responsible to pay for 

copayment/coinsurance for eligible health services during the calendar year. This plan has an 

individual and family maximum out-of-pocket limit.

Certain costs that you incur do not apply toward the maximum out-of-pocket limit. These include:

 All costs for non-covered services

Calculations; determination of negotiated charge; determination of benefits 

provisions

Your financial responsibility for the costs of services will be calculated on the basis of when the 

service or supply is provided, not when payment is made. Benefits will be pro-rated to account for 

treatment or portions of stays that occur in more than one calendar year. Determinations regarding 

when benefits are covered are subject to the terms and conditions of the EOC.

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