AETNA ADVANTAGE PLANS FOR INDIVIDUALS,
FAMILIES AND THE SELF-EMPLOYED
NEW PROVISIONS EFFECTIVE SEPTEMBER 23, 2010
This information is an addendum to the printed materials you received.
©2010 Aetna Inc.
13.03.536.1 (7/10)
The federal health care
reform legislation, known
as the Patient Protection
and Affordable Care Act,
was signed into law
on March 23, 2010 by
President Obama.
The following health care
reform changes are effective
on September 23, 2010:
• Allow dependent coverage up
to age 26
• Remove lifetime benefi t limits –
based on dollar amounts
• Take away cost-sharing obligations
for preventive services (In network)
• Eliminate pre-existing condition
exclusions for dependent children
(under 19 years of age)
Please note that some previously
printed materials do not refl ect these
changes. However, the new provisions
are in effect for plans with an effective
date on or after September 23, 2010,
and your Aetna Advantage Plan does
comply with the new federal health
care reform legislation.
If you have any questions, please talk to
your broker or call 1-800-MY-HEALTH.
Please note that in addition to health care reform changes, coverage for children only may
no longer be available in your state. Also, all plans described in the printed material you
received may not currently be available in your state.
Aetna Advantage Plans for Individuals, Families and the Self-Employed are underwritten by Aetna
Life Insurance Company (Aetna) directly and/or through an out-of-state blanket trust or Aetna
Health Inc. In some states, individuals may qualify as a business group of one and may be eligible
for guaranteed issue, small group health plans. These plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
Take charge of your health.
We’re here to help.
AETNA ADVANTAGE PLANS FOR INDIVIDUALS,
FAMILIES AND THE SELF-EMPLOYED IN MISSOURI
AA.02.305.1-MO (1/10) B
The information you
need to choose quality
and affordable health
insurance coverage.
Choose Aetna, choose affordable coverage
Aetna Advantage Plans for Individuals, Families and the Self-Employed are underwritten
by Aetna Life Insurance Company (Aetna) directly and/or through an out-of-state blanket
trust. In some states, individuals may qualify as a business group of one and may be
eligible for guaranteed issue, small group health plans. These plans are medically underwritten
and you may be declined coverage in accordance with your health condition.
UNDERSTANDING YOUR CHOICES
See what plans are available
AETNA ADVANTAGE PLAN DETAILS
Choose the insurance coverages that are right for you
MORE VALUE WITH AETNA SPECIAL PROGRAMS
Substantial savings on programs to help you stay healthy
WHAT YOU NEED TO KNOW
Learn more about what’s included
1)
2)
3)
4)
1-800-MY HEALTH | www.aetnaindividual.com
Here are our top reasons why the Aetna Advantage
plans offer some of the best choices and value to
help meet your health coverage needs.
Affordable quality & choices
Choose from a wide range of health
insurance plans that offer excellent
quality. Our plans are designed for
maximum value, with lower monthly
premiums, plus benefits for preventive care.
You can choose how much to spend in
premiums versus out-of-pocket expenses.
Robust coverage,
competitive costs
We offer plans with valuable features
which may include:
n
An excellent combination of
quality coverage and competitively
priced premiums.
n
The freedom to see doctors whenever
you need to, with no referrals needed.
n
Covers preventive care, prescription
drugs, doctor visits, hospitalization
and children’s immunizations.
n
No deductible for well-women exams
when you visit a network provider.
n
No claim forms to fill out when you
use a network provider.
n
Aetna’s nationwide provider network
offers you a vast selection of licensed
physicians and hospitals.
Family coverage
Apply for coverage for yourself, your
spouse, and children, or even just your
children. Coverage can include prescription
drugs, doctor visits, hospitalization and
preventive care services.
Tax advantages
We also offer High Deductible plans that
are compatible with tax-advantaged Health
Savings Accounts (HSAs). You can contribute
money to your HSA tax-free. That money
earns interest tax-free. And qualified
withdrawals for medical expenses are
tax-free, too.
Help with health information
Need health information fast? We offer
secure Internet access to reliable health
tools and resources. Learn more about
Aetna Navigator
®
and the Informed
Health
®
Line in Section 3 - More Value
with Aetna Special Programs.
Coverage when you travel
Like to travel? You’re covered by a
nationwide network of doctors
and hospitals that accept Aetna’s
negotiated fees.
1
HAVE QUESTIONS?
Just e-mail [email protected] or call 1-800-MY-HEALTH (1-800-694-3258).
WANT A QUOTE NOW?
Visit www.aetnaindividual.com or call 1-800-MY-HEALTH (1-800-694-3258).
Choose Aetna, choose affordable coverage
ENROLL ONLINE
OR BY MAIL
Use this guide to narrow down
your plan choices. Then, get a free
quote and enroll for a policy either
online or by mail.
ONLINE:
1. Visit www.aetnaindividual.com.
2. Choose your state.
3. Choose the best plan for you.
4. Click “Get A Quote.”
5. Apply online and submit an
electronic form of payment.
(Or mail the enclosed enrollment
form with one form of payment
selected.)
6. Track the status of your
enrollment form by clicking the
site’s Apps tab.
BY MAIL:
Complete and mail the enclosed
enrollment form, in the envelope
provided, with one form of
payment selected.
About HSAs
Many of our high-deductible plans are Health
Savings Account (HSA) Compatible, offering
you lower premiums and tax advantaged
savings. An HSA is a personal account that
lets you pay for qualified medical expenses
with tax advantaged funds. You or an eligible
family member make contributions to your
HSA tax-free, and those dollars earn interest
tax-free. Then, when you make withdrawals
from your account to pay for qualified health
care expenses, they’re tax-free, too.
It’s easy to establish a
Health Savings Account…
Simply enroll in an Aetna HSA Compatible
High Deductible Health Plan and you will
automatically have an HSA opened through
Bank of America. You will also receive a debit
card and a welcome package with additional
information to get you started.
If you do not wish to set up an HSA, you can
opt out by calling Bank of America – or the
account will be automatically canceled after
90 days if the debit card is not activated or
if you do not enroll online.
Why choose an Aetna
HealthFund HSA?
n
No set-up fees
n
No monthly administration fee
n
No withdrawal forms required
n
Convenient access to HSA funds via debit
card or online
n
Track HSA activity online
Is your doctor in the
Aetna network?
Which local physicians, hospitals, pharmacies
and eyewear providers participate in the
nationwide Aetna Advantage Plan network?
Visit www.aetna.com/docfind/custom/
advplans. Or call 1-800-694-3258 and ask for
a directory of providers.
Get more from your Aetna plan
Cover just your children
Aetna Advantage Plans are also available for
children only, which means you can enroll your
child even if no other family member enrolls.
Coverage includes immunizations, well-child
visits, emergency room and dental preventive
services (if a dental plan is selected).
Note: when an HSA Compatible plan is selected
for child only enrollment, an HSA account is not
available for the child.
Add Dental PPO Max
With the Aetna Advantage Dental PPO Max
insurance plan, you can obtain services from
either a participating or non-participating
dentist. Participating dentists have agreed
to provide services at a negotiated rate
for both covered services, as well as non-
covered services such as cosmetic tooth
whitening and orthodontic care, so you
generally pay less out-of-pocket. You also
have the flexibility to visit a dentist who does
not participate in Aetna’s network, though
you will not have access to negotiated fees.
Dental coverage is offered only if medical
coverage is obtained.
Understanding your
Aetna Advantage plan choices
1)
Our plans are designed to offer
you quality coverage at an excellent
value. Coverage can include
prescription drugs, doctor visits,
hospitalization and preventive
care services.
Generally speaking, the lower your
“premiums,” or monthly payments, the
higher your “deductible,” which is the
amount you pay out of pocket before
the plan begins paying for expenses.
You’ll pay less by using “in-network”
doctors, hospitals, pharmacies and other
health care providers who participate in
Aetna’s nationwide network than by using
“out-of-network” doctors.
Visit www.planforyourhealth.com for
an in-depth list of terms in this brochure
and what they mean.
1-800-MY HEALTH | www.aetnaindividual.com
2
Understanding your
Aetna Advantage plan choices
Deductible – A fixed yearly dollar
amount you pay before the benefits of
the plan policy start.
Coinsurance – The dollar amount that
the plan and you pay for covered benefits
after the deductible is paid.
Copayment (Copay) – A fixed dollar
amount that you must contribute toward
the cost of covered medical services
under a health plan. For HSA compatible
plans, copayment will apply to your
out-of-pocket max.
Exclusions and Limitations — Specific
conditions or circumstances that are not
covered under a plan.
Lifetime Maximum – The total dollar
amount of benefits you may receive, or the
limited number of particular services you
may receive, over the term of the policy.
Out-of-Pocket Maximum – The
amounts such as coinsurance and
deductibles that an individual is required
to contribute toward the cost of health
services covered by the benefits plan.
Premium – The amount charged, often
in installments, for an insurance policy.
Pre-existing Condition – A health
condition (other than a pregnancy) or
medical problem including the use of
prescription drugs that was diagnosed or
treated before getting insurance from a
new health plan.
* Plan For Your Health is a public education
program from Aetna and the Financial
Planning Association.
WHAT DOES
ThaT MEAN?
Here are a few definitions of
terms you’ll see throughout
this brochure. For a more in-
depth list of terms, please visit
www.planforyourhealth.com.*
3
AETNA’S MISSOURI RATINGS AREAS*
Your rates will depend on the area in which your county is located.
For more information or a quote on what your rate would be, call 1-800-MY HEALTH.
* Networks may not be available in all ZIP codes and are subject to change.
Area 1 Counties
Adair
Andrew
Atchison
Benton
Buchanan
Cass
Clark
Clay
Clinton
Daviess
Dekalb
Dent
Gentry
Harrison
Holt
Howell
Jackson
Knox
Laclede
Lafayette
Lewis
Linn
Macon
Marion
Mercer
Nodaway
Pike
Platte
Putnam
Ralls
Ray
Saint Clair
Schuyler
Scotland
Shannon
Shelby
Sullivan
Texas
Vernon
Worth
Area 2 Counties
Audrain
Barton
Bates
Bollinger
Boone
Butler
Caldwell
Callaway
Camden
Cape Girardeau
Carroll
Carter
Chariton
Cole
Cooper
Dunklin
Gasconade
Grundy
Henry
Howard
Iron
Jasper
Johnson
Livingston
Madison
Maries
McDonald
Miller
Mississippi
Moniteau
Monroe
Montgomery
Morgan
New Madrid
Newton
Oregon
Osage
Pemiscot
Perry
Pettis
Phelps
Pulaski
Randolph
Reynolds
Ripley
Saline
Scott
Stoddard
Wayne
Area 3 Counties
Barry
Cedar
Christian
Dade
Dallas
Douglas
Greene
Hickory
Lawrence
Ozark
Polk
Stone
Taney
Webster
Wright
Area 4 Counties
Crawford
Franklin
Jefferson
Lincoln
Saint Charles
Saint Francois
Saint Louis
Saint Louis City
Sainte Genevieve
Warren
Washington
2) Plan Details
1-800-MY HEALTH | www.aetnaindividual.com
4
* Maximum applies to combined in and out-of-
network benefits.
** Copay is billed separately and not due at time of
service. Copay does not count towards coinsurance
or out-of-pocket maximum.
+ Payment for out-of-network facility covered
expenses is determined based on Aetna’s Market
Fee Schedule. Payment for out-of-network non-
facility covered expenses is determined based on the
negotiated charge that would apply if such services
were received from a Network Provider.
First Dollar PPO
plan options
Robust coverage and lower
out-of-pocket expenses with
no deductibles when you
choose a network provider
Featuring:
n
Lower copay for in-network
provider visits
n
No deductible for generic
prescription drugs
Plus:
n
Coverage for office visits to your
primary care physician and specialists
n
No claim forms to fill out when you
visit a network provider
n
No referrals required to see a specialist
n
No waiting period for routine
physical exams
n
100% annual routine GYN exam
coverage — no waiting period,
no dollar maximum and no copay
or deductible when you visit a
network provider
n
Coverage for prescription drugs
n
Coverage for routine physicals including
lab work and X-rays
n
100% coverage for in-network
childhood immunizations
First Dollar PPO 30 First Dollar PPO 40
MEMBER BENEFITS
In-Network Out-of-Network
+
In-Network Out-of-Network
+
Deductible
Individual
Family
$0
$0
$5,000
$10,000
$0
$0
$7,000
$14,000
Coinsurance
(Member’s responsibility)
30% up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
40% up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
$0 once out-of-pocket max. is satisfied
$0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$7,500
$15,000
$7,500
$15,000
$12,500
$25,000
$5,500
$11,000
Out-of-Pocket Maximum
Individual
Family
$7,500
$15,000
$12,500
$25,000
$12,500
$25,000
$12,500
$25,000
Includes deductible
Includes deductible
Lifetime Maximum* per insured
$5,000,000
$5,000,000
Non-Specialist Office Visit
Unlimited visits
General Physician, Family
Practitioner, Pediatrician or Internist
$30 copay 50%
after deductible
$40 copay 50%
after deductible
Specialist Visit
Unlimited visits
$40 copay 50%
after deductible
$50 copay 50%
after deductible
Hospital Admission
30% 50%
after deductible
40% 50%
after deductible
Outpatient Surgery
30% 50%
after deductible
40% 50%
after deductible
Urgent Care Facility
$50 copay 50%
after deductible
$50 copay 50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
30% coinsurance
$100 copay** (waived if admitted)
40% coinsurance
Annual Routine Gyn Exam
No waiting period, no calendar year
max. Annual Pap/Mammogram
$0 copay 50%
after deductible
$0 copay 50%
after deductible
Maternity
Not covered
Except for pregnancy complications
Not covered
Except for pregnancy complications
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$30 copay 50%
after deductible
$40 copay 50%
after deductible
Includes lab work and X-rays
Includes lab work and X-rays
Lab/X-Ray
30% 50%
after deductible
40% 50%
after deductible
Skilled Nursing —
in lieu of hospital
30 days per calendar year*
30% 50%
after deductible
40% 50%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
30% 50%
after deductible
40% 50%
after deductible
Aetna will pay a max. of $25 per visit*
Aetna will pay a max. of $25 per visit*
Home Health Care —
in lieu of hospital
30 visits per calendar year*
30% 50%
after deductible
40% 50%
after deductible
Durable Medical Equipment
Aetna will pay up to $2,000 per
calendar year*
30% 50%
after deductible
40% 50%
after deductible
PHARMACY
Pharmacy Deductible
per individual
$500 $500
Not Applicable Not Applicable
Generic
Oral Contraceptives Included
$15 copay
deductible waived
$15 copay
plus 50%
deductible waived
$20 copay $20 copay
plus 50%
Preferred Brand
Oral Contraceptives Included
$40 copay
after deductible
$40 copay
plus 50%
after deductible
Not covered
Aetna Discount
Applies
Not covered
Non-Preferred Brand
Oral Contraceptives Included
$60 copay
after deductible
$60 copay
plus 50%
after deductible
Not covered
Aetna Discount
Applies
Not covered
Calendar Year Maximum
per individual*
Unlimited Unlimited
Unlimited Unlimited
5
* Maximum applies to combined in and out-of-
network benefits.
** Copay is billed separately and not due at time of
service. Copay does not count towards coinsurance
or out-of-pocket maximum.
+ Payment for out-of-network facility covered
expenses is determined based on Aetna’s Market
Fee Schedule. Payment for out-of-network non-
facility covered expenses is determined based on the
negotiated charge that would apply if such services
were received from a Network Provider.
Robust coverage and lower
monthly payments balanced
with a deductible…where you
don’t want to pay a lot for
frequent doctor visits
Featuring:
n
Health insurance coverage with
lower monthly premiums and
varying deductible levels
PPO
plan options
Plus:
n
Coverage for office visits to your
primary care physician and specialists
n
No claim forms to fill out when you
visit a network provider
n
No referrals required to see a specialist
n
No waiting period for routine
physical exams
n
100% annual routine GYN exam
coverage — no waiting period,
no dollar maximum and no copay
or deductible when you visit a
network provider
n
Coverage for prescription drugs
n
Coverage for routine physicals
including lab work and X-rays
n
100% coverage for in-network
childhood immunizations
PPO 1000 PPO 1500
MEMBER BENEFITS
In-Network Out-of-Network
+
In-Network Out-of-Network
+
Deductible
Individual
Family
$1,000
$2,000
$2,000
$4,000
$1,500
$3,000
$3,000
$6,000
Coinsurance
(Member’s responsibility)
20% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
20% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
$0 once out-of-pocket max. is satisfied
$0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$2,000
$4,000
$8,000
$16,000
$1,500
$3,000
$7,000
$14,000
Out-of-Pocket Maximum
Individual
Family
$3,000
$6,000
$10,000
$20,000
$3,000
$6,000
$10,000
$20,000
Includes deductible
Includes deductible
Lifetime Maximum* per insured
$5,000,000
$5,000,000
Non-Specialist Office Visit
Unlimited visits
General Physician, Family
Practitioner, Pediatrician or Internist
$20 copay
deductible waived
50%
after deductible
$25 copay
deductible waived
50%
after deductible
Specialist Visit
Unlimited visits
$30 copay
deductible waived
50%
after deductible
$35 copay
deductible waived
50%
after deductible
Hospital Admission
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period, no calendar year
max. Annual Pap/Mammogram
$0 copay
deductible waived
50%
after deductible
$0 copay
deductible waived
50%
after deductible
Maternity Not covered
Except for pregnancy complications
Not covered
Except for pregnancy complications
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$20 copay
deductible waived
50%
after deductible
$25 copay
deductible waived
50%
after deductible
Includes lab work and X-rays
Includes lab work and X-rays
Lab/X-Ray
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Skilled Nursing —
in lieu of hospital
30 days per calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Aetna will pay a max. of $25 per visit*
Aetna will pay a max. of $25 per visit*
Home Health Care —
in lieu of hospital
30 visits per calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Durable Medical Equipment
Aetna will pay up to $2,000 per
calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
PHARMACY
Pharmacy Deductible
per individual
$250 $250
$250 $250
Does not apply to generic Does not apply to generic
Generic
Oral Contraceptives Included
$15 copay
deductible waived
$15 copay
plus 50%
deductible waived
$15 copay
deductible waived
$15 copay
plus 50%
deductible waived
Preferred Brand
Oral Contraceptives Included
$35 copay
after deductible
$35 copay
plus 50%
after deductible
$35 copay
after deductible
$35 copay
plus 50% after
deductible
Non-Preferred Brand
Oral Contraceptives Included
$50 copay
after deductible
$50 copay
plus 50%
after deductible
$50 copay
after deductible
$50 copay
plus 50% after
deductible
Calendar Year Maximum
per individual*
Unlimited Unlimited
Unlimited Unlimited
1-800-MY HEALTH | www.aetnaindividual.com
6
Robust coverage and lower
monthly payments balanced
with a deductible…where you
don’t want to pay a lot for
frequent doctor visits
Featuring:
n
Health insurance coverage with
lower monthly premiums and
varying deductible levels
Plus:
n
Coverage for office visits to your
primary care physician and specialists
n
No claim forms to fill out when you
visit a network provider
n
No referrals required to see a specialist
n
No waiting period for routine
physical exams
n
100% annual routine GYN exam
coverage — no waiting period,
no dollar maximum and no copay
or deductible when you visit a
network provider
n
Coverage for prescription drugs
n
Coverage for routine physicals
including lab work and X-rays
n
100% coverage for in-network
childhood immunizations
* Maximum applies to combined in and out-of-
network benefits.
** Copay is billed separately and not due at time of
service. Copay does not count towards coinsurance
or out-of-pocket maximum.
+ Payment for out-of-network facility covered
expenses is determined based on Aetna’s Market
Fee Schedule. Payment for out-of-network non-
facility covered expenses is determined based on the
negotiated charge that would apply if such services
were received from a Network Provider.
PPO
plan options
PPO 2500 PPO 5000
MEMBER BENEFITS
In-Network Out-of-Network
+
In-Network Out-of-Network
+
Deductible
Individual
Family
$2,500
$5,000
$5,000
$10,000
$5,000
$10,000
$10,000
$20,000
Coinsurance
(Member’s responsibility)
20% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
20% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
$0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$2,500
$5,000
$5,000
$10,000
$5,000
$10,000
$2,500
$5,000
Out-of-Pocket Maximum
Individual
Family
$5,000
$10,000
$10,000
$20,000
$10,000
$20,000
$12,500
$25,000
Includes deductible Includes deductible
Lifetime Maximum* per insured
$5,000,000 $5,000,000
Non-Specialist Office Visit
Unlimited visits
General Physician, Family
Practitioner, Pediatrician or Internist
$30 copay
deductible waived
50%
after deductible
$40 copay
deductible waived
50%
after deductible
Specialist Visit
Unlimited visits
$40 copay
deductible waived
50%
after deductible
$50 copay
deductible waived
50%
after deductible
Hospital Admission
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period, no calendar year
max. Annual Pap/Mammogram
$0 copay
deductible waived
50%
after deductible
$0 copay
deductible waived
50%
after deductible
Maternity
Not covered
Except for pregnancy complications
Not covered
Except for pregnancy complications
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$30 copay
deductible waived
50%
after deductible
$40 copay
deductible waived
50%
after deductible
Includes lab work and X-rays Includes lab work and X-rays
Lab/X-Ray
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Skilled Nursing —
in lieu of hospital
30 days per calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit*
Home Health Care —
in lieu of hospital
30 visits per calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Durable Medical Equipment
Aetna will pay up to $2,000 per
calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
PHARMACY
Pharmacy Deductible
per individual
$500 $500 $500 $500
Does not apply to generic Does not apply to generic
Generic
Oral Contraceptives Included
$15 copay
deductible waived
$15 copay
plus 50%
deductible waived
$15 copay
deductible waived
$15 copay
plus 50%
deductible waived
Preferred Brand
Oral Contraceptives Included
$35 copay
after deductible
$35 copay
plus 50%
after deductible
$35 copay
after deductible
$35 copay
plus 50%
after deductible
Non-Preferred Brand
Oral Contraceptives Included
$50 copay
after deductible
$50 copay plus
50%
after deductible
$50 copay
after deductible
$50 copay
plus 50%
after deductible
Calendar Year Maximum
per individual*
Unlimited Unlimited Unlimited Unlimited
PPO
High Deductible
plan options
Lower premium costs…and
an HSA-compatible plan that
offers tax advantaged savings
Featuring:
n
0% coinsurance in network after
your deductible is met
n
Lower monthly premiums, higher
annual deductibles (at least $3,000
for individuals and $6,000 for families)
n
Can be paired with a tax-advantaged
Health Savings Account (HSA)
Plus:
n
Coverage for office visits to your
primary care physician and specialists
n
No claim forms to fill out when you
visit a network provider
n
No referrals required to see a specialist
n
No waiting period for routine
physical exams
n
100% annual routine GYN exam
coverage — no waiting period,
no dollar maximum and no copay
or deductible when you visit a
network provider
n
Coverage for prescription drugs
n
Coverage for routine physicals
including lab work and X-rays
n
100% coverage for in-network
childhood immunizations
7
* Maximum applies to combined in and out-of-
network benefits.
** Copay is billed separately and not due at time of
service. Copay does not count towards coinsurance
or out-of-pocket maximum.
+ Payment for out-of-network facility covered
expenses is determined based on Aetna’s Market
Fee Schedule. Payment for out-of-network non-
facility covered expenses is determined based on the
negotiated charge that would apply if such services
were received from a Network Provider.
PPO High Deductible 3000
(HSA Compatible)
PPO High Deductible 5000
(HSA Compatible)
MEMBER BENEFITS
In-Network Out-of-Network
+
In-Network Out-of-Network
+
Deductible
Individual
Family
$3,000
$6,000
$6,000
$12,000
$5,000
$10,000
$10,000
$20,000
Coinsurance
(Member’s responsibility)
0% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
0% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
$0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$0
$0
$6,500
$13,000
$0
$0
$2,500
$5,000
Out-of-Pocket Maximum
Individual
Family
$3,000
$6,000
$12,500
$25,000
$5,000
$10,000
$12,500
$25,000
Includes deductible Includes deductible
Lifetime Maximum* per insured
$5,000,000 $5,000,000
Non-Specialist Office Visit
Unlimited visits
General Physician, Family
Practitioner, Pediatrician or Internist
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Specialist Visit
Unlimited visits
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Hospital Admission
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Outpatient Surgery
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Urgent Care Facility
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Emergency Room
$0 copay after deductible $0 copay after deductible
Annual Routine Gyn Exam
No waiting period, no calendar year
max. Annual Pap/Mammogram
$0 copay
deductible waived
50%
after deductible
$0 copay
deductible waived
50%
after deductible
Maternity Not covered
Except for pregnancy complications
Not covered
Except for pregnancy complications
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$20 copay
deductible waived
50%
after deductible
$25 copay
deductible waived
50%
after deductible
Includes lab work and X-rays Includes lab work and X-rays
Lab/X-Ray
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Skilled Nursing —
in lieu of hospital
30 days per calendar year*
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
24 visits per calendar year*
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Aetna will pay a max. of $25 per visit* Aetna will pay a max. of $25 per visit*
Home Health Care —
in lieu of hospital
30 visits per calendar year*
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
Durable Medical Equipment
Aetna will pay up to $2,000 per
calendar year*
0%
after deductible
50%
after deductible
0%
after deductible
50%
after deductible
PHARMACY
Pharmacy Deductible
per individual
Integrated Medical/
Rx Deductible
Integrated Medical/
Rx Deductible
Integrated Medical/
Rx Deductible
Integrated Medical/
Rx Deductible
Generic
Oral Contraceptives Included
0% after Medical/
Rx deductible
50% after Medical/
Rx deductible
0% after Medical/
Rx deductible
50% after Medical/
Rx deductible
Preferred Brand
Oral Contraceptives Included
0% after Medical/
Rx deductible
50% after Medical/
Rx deductible
0% after Medical/
Rx deductible
50% after Medical/
Rx deductible
Non-Preferred Brand
Oral Contraceptives Included
0% after Medical/
Rx deductible
50% after Medical/
Rx deductible
0% after Medical/
Rx deductible
50% after Medical/
Rx deductible
Calendar Year Maximum
per individual*
Unlimited Unlimited Unlimited Unlimited
1-800-MY HEALTH | www.aetnaindividual.com
8
* Maximum applies to combined in and
out-of-network benefits.
** Copay is billed separately and not due at time
of service. Copay does not count towards
coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility covered
expenses is determined based on Aetna’s Market
Fee Schedule. Payment for out-of-network non-
facility covered expenses is determined based on
the negotiated charge that would apply if such
services were received from a Network Provider.
PPO Value
plan options
Affordability — a balance
of lower monthly premiums
and quality coverage…
where you want to cap the
amount you’ll spend on total
medical expenses each year
Featuring:
n
Lower monthly premiums
(that’s the “Value” part)
n
No deductible for generic
prescription drugs
Plus:
n
Coverage for office visits to your
primary care physician and specialists
n
No claim forms to fill out when you
visit a network provider
n
No referrals required to see a specialist
n
No waiting period for routine
physical exams
n
100% annual routine GYN exam
coverage — no waiting period,
no dollar maximum and no copay
or deductible when you visit a
network provider
n
Coverage for prescription drugs
n
Coverage for routine physicals
including lab work and X-rays
n
100% coverage for in-network
childhood immunizations
PPO Value 2500 PPO Value 5000
MEMBER BENEFITS
In-Network Out-of-Network
+
In-Network Out-of-Network
+
Deductible
Individual
Family
$2,500
$5,000
$5,000
$10,000
$5,000
$10,000
$10,000
$20,000
Coinsurance
(Member’s responsibility)
30% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
30% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
$0 once out-of-pocket max. is satisfied
$0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$2,500
$5,000
$5,000
$10,000
$5,000
$10,000
$2,500
$5,000
Out-of-Pocket Maximum
Individual
Family
$5,000
$10,000
$10,000
$20,000
$10,000
$20,000
$12,500
$25,000
Includes deductible
Includes deductible
Lifetime Maximum* per insured
$1,000,000
$1,000,000
Non-Specialist Office Visit
Unlimited Visits
General Physician, Family
Practitioner, Pediatrician or Internist
Visits 1-2 $30 copay,
deductible waived;
Visit 3+ 30% after
deductible. Spec.
and non-spec share
visit max
50%
after deductible
Visits 1-2 $30 copay,
deductible waived;
Visit 3+ 30% after
deductible. Spec.
and non-spec share
visit max
50%
after deductible
Specialist Visit
Unlimited Visits
Visits 1-2 $30 copay,
deductible waived;
Visit 3+ 30% after
deductible. Spec.
and non-spec share
visit max
50%
after deductible
Visits 1-2 $30 copay,
deductible waived;
Visit 3+ 30% after
deductible. Spec.
and non-spec share
visit max
50%
after deductible
Hospital Admission
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Outpatient Surgery
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
30% coinsurance after deductible
$100 copay** (waived if admitted)
30% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period, no calendar year
max. Annual Pap/Mammogram
$0 copay
deductible waived
50%
after deductible
$0 copay
deductible waived
50%
after deductible
Maternity Not covered
Except for pregnancy complications
Not covered
Except for pregnancy complications
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$50 copay
deductible waived
50%
after deductible
$50 copay
deductible waived
50%
after deductible
Includes lab work and X-rays
Includes lab work and X-rays
Lab/X-Ray
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Skilled Nursing —
in lieu of hospital
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Aetna will pay up to $25 per visit max.*
Aetna will pay up to $25 per visit max.*
Home Health Care —
in lieu of hospital
30 visits per calendar year*
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Durable Medical Equipment
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
PHARMACY
Pharmacy Deductible
per individual
$500 $500
$500 $500
Does not apply to generic
Does not apply to generic
Generic
Oral Contraceptives Included
$20 copay
deductible waived
$20 copay
plus 50%
deductible waived
$20 copay
deductible waived
$20 copay
plus 50%
deductible waived
Preferred Brand
Oral Contraceptives Included
$40 copay
after deductible
$40 copay
plus 50%
after deductible
$40 copay
after deductible
$40 copay
plus 50%
after deductible
Non-Preferred Brand
Oral Contraceptives Included
Not covered
Aetna Discount
Applies
Not covered
Not covered
Aetna Discount
Applies
Not covered
Calendar Year Maximum
per individual*
$5,000 $5,000
$5,000 $5,000
9
* Maximum applies to combined in and
out-of-network benefits.
** Copay is billed separately and not due at time
of service. Copay does not count towards
coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility covered
expenses is determined based on Aetna’s Market
Fee Schedule. Payment for out-of-network non-
facility covered expenses is determined based on
the negotiated charge that would apply if such
services were received from a Network Provider.
Preventive and
Hospital Care
plan options
Affordability is one of your
top priorities and you use only
basic health care services…
and want to keep your
monthly premiums lower
Featuring:
n
Health insurance coverage with
lower monthly premiums and varying
deductible levels.
Plus:
n
No claim forms to fill out when you
visit a network provider
n
No waiting period for routine
physical exams
n
100% annual routine GYN exam
coverage — no waiting period,
no dollar maximum and no copay
or deductible when you visit a
network provider
n
Coverage for routine physicals including
lab work and X-rays
n
100% coverage for in-network
childhood immunizations
PPO Value 2500 PPO Value 5000
MEMBER BENEFITS
In-Network Out-of-Network
+
In-Network Out-of-Network
+
Deductible
Individual
Family
$2,500
$5,000
$5,000
$10,000
$5,000
$10,000
$10,000
$20,000
Coinsurance
(Member’s responsibility)
30% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
30% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
$0 once out-of-pocket max. is satisfied
$0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$2,500
$5,000
$5,000
$10,000
$5,000
$10,000
$2,500
$5,000
Out-of-Pocket Maximum
Individual
Family
$5,000
$10,000
$10,000
$20,000
$10,000
$20,000
$12,500
$25,000
Includes deductible
Includes deductible
Lifetime Maximum* per insured
$1,000,000
$1,000,000
Non-Specialist Office Visit
Unlimited Visits
General Physician, Family
Practitioner, Pediatrician or Internist
Visits 1-2 $30 copay,
deductible waived;
Visit 3+ 30% after
deductible. Spec.
and non-spec share
visit max
50%
after deductible
Visits 1-2 $30 copay,
deductible waived;
Visit 3+ 30% after
deductible. Spec.
and non-spec share
visit max
50%
after deductible
Specialist Visit
Unlimited Visits
Visits 1-2 $30 copay,
deductible waived;
Visit 3+ 30% after
deductible. Spec.
and non-spec share
visit max
50%
after deductible
Visits 1-2 $30 copay,
deductible waived;
Visit 3+ 30% after
deductible. Spec.
and non-spec share
visit max
50%
after deductible
Hospital Admission
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Outpatient Surgery
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Urgent Care Facility
$50 copay
deductible waived
50%
after deductible
$50 copay
deductible waived
50%
after deductible
Emergency Room
$100 copay** (waived if admitted)
30% coinsurance after deductible
$100 copay** (waived if admitted)
30% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period, no calendar year
max. Annual Pap/Mammogram
$0 copay
deductible waived
50%
after deductible
$0 copay
deductible waived
50%
after deductible
Maternity Not covered
Except for pregnancy complications
Not covered
Except for pregnancy complications
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$50 copay
deductible waived
50%
after deductible
$50 copay
deductible waived
50%
after deductible
Includes lab work and X-rays
Includes lab work and X-rays
Lab/X-Ray
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Skilled Nursing —
in lieu of hospital
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Aetna will pay up to $25 per visit max.*
Aetna will pay up to $25 per visit max.*
Home Health Care —
in lieu of hospital
30 visits per calendar year*
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
Durable Medical Equipment
30%
after deductible
50%
after deductible
30%
after deductible
50%
after deductible
PHARMACY
Pharmacy Deductible
per individual
$500 $500
$500 $500
Does not apply to generic
Does not apply to generic
Generic
Oral Contraceptives Included
$20 copay
deductible waived
$20 copay
plus 50%
deductible waived
$20 copay
deductible waived
$20 copay
plus 50%
deductible waived
Preferred Brand
Oral Contraceptives Included
$40 copay
after deductible
$40 copay
plus 50%
after deductible
$40 copay
after deductible
$40 copay
plus 50%
after deductible
Non-Preferred Brand
Oral Contraceptives Included
Not covered
Aetna Discount
Applies
Not covered
Not covered
Aetna Discount
Applies
Not covered
Calendar Year Maximum
per individual*
$5,000 $5,000
$5,000 $5,000
Preventive and
Hospital Care 1250
Preventive and
Hospital Care 3000
(HSA Compatible)
MEMBER BENEFITS
In-Network Out-of-Network
+
In-Network Out-of-Network
+
Deductible
Individual
Family
$1,250
$2,500
$2,500
$5,000
$3,000
$6,000
$6,000
$12,000
Coinsurance
(Member’s responsibility)
20% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
20% after
deductible up to
out-of-pocket max.
50% after
deductible up to
out-of-pocket max.
$0 once out-of-pocket max. is satisfied $0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$3,000
$6,000
$7,500
$15,000
$2,000
$4,000
$4,000
$8,000
Out-of-Pocket Maximum
Individual
Family
$4,250
$8,500
$10,000
$20,000
$5,000
$10,000
$10,000
$20,000
Includes deductible Includes deductible
Lifetime Maximum* per insured
$1,000,000 $1,000,000
Non-Specialist Office Visit
General Physician, Family
Practitioner, Pediatrician or Internist
Not covered Not covered Not covered Not covered
Specialist Visit
Not covered Not covered Not covered Not covered
Hospital Admission
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Urgent Care Facility
Not covered Not covered Not covered Not covered
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period, no calendar year
max. Annual Pap/Mammogram
$0 copay
deductible waived
50%
after deductible
$0 copay
deductible waived
50%
after deductible
Maternity Not covered
Except for pregnancy complications
Not covered
Except for pregnancy complications
Preventive Health —
Routine Physical
Aetna will pay up to $200 per exam*
No waiting period
$25 copay
deductible waived
50%
after deductible
$35 copay
deductible waived
50%
after deductible
Includes lab work and X-rays Includes lab work and X-rays
Lab/X-Ray
Not covered Not covered Not covered Not covered
Skilled Nursing —
in lieu of hospital
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Physical/Occupational Therapy
and Chiropractic Care
Not covered Not covered Not covered Not covered
Home Health Care —
in lieu of hospital
30 visits per calendar year*
20%
after deductible
50%
after deductible
20%
after deductible
50%
after deductible
Durable Medical Equipment
Not covered Not covered Not covered Not covered
PHARMACY
Pharmacy Deductible
per individual
Not Applicable Not Applicable Not Applicable Not Applicable
Generic
Oral Contraceptives Included
$15 copay $15 copay plus
50%
Not covered
Aetna Discount
Applies
Not covered
Preferred Brand
Oral Contraceptives Included
Not covered
Aetna Discount
Applies
Not covered Not covered
Aetna Discount
Applies
Not covered
Non-Preferred Brand
Oral Contraceptives Included
Not covered
Aetna Discount
Applies
Not covered Not covered
Aetna Discount
Applies
Not covered
Calendar Year Maximum
per individual*
Unlimited Unlimited Not Applicable Not Applicable
MEMBER BENEFITS
Preferred NonPreferred
Annual Deductible per Member
(Does not apply to Diagnostic and Preventive Services)
$25;
$75 family maximum
$25;
$75 family maximum
Annual Maximum Benefit Unlimited Unlimited
DIAGNOSTIC SERVICES
Oral exams
Periodic oral exam 100% deductible waived 100% deductible waived
Comprehensive oral exam 100% deductible waived 100% deductible waived
Problem-focused oral exam 100% deductible waived 100% deductible waived
X-rays
Bitewing — single film 100% deductible waived 100% deductible waived
Complete series 100% deductible waived 100% deductible waived
PREVENTIVE SERVICES
Adult cleaning 100% deductible waived 100% deductible waived
Child cleaning 100% deductible waived 100% deductible waived
Sealants — per tooth Discount Not covered
Fluoride application — with cleaning 100% deductible waived 100% deductible waived
Space maintainers Discount Not covered
BASIC SERVICES
Amalgam fillings —
2 surfaces
100% after deductible 100% after deductible
Resin fillings — 2 surfaces Discount Not covered
Oral Surgery
Extraction — exposed root or erupted tooth Discount Not covered
Extraction of impacted tooth — soft tissue Discount Not covered
MAJOR SERVICES
Complete upper denture Discount Not covered
Partial upper denture
(resin based)
Discount Not covered
Crown — Porcelain with noble metal Discount Not covered
Pontic — Porcelain with noble metal Discount Not covered
Inlay — Metallic (3 or more surfaces) Discount Not covered
Oral Surgery
Removal of impacted tooth — partially bony Discount Not covered
Endodontic Services
Bicuspid root canal therapy Discount Not covered
Molar root canal therapy Discount Not covered
Periodontic Services
Scaling & root planing — per quadrant Discount Not covered
Osseous surgery — per quadrant Discount Not covered
ORTHODONTIC SERVICES
Discount Not covered
Aetna Advantage Plan options
Individual Dental PPO Max plan
Access to negotiated discounts: members are eligible to receive non-covered services, including cosmetic services such as tooth whitening, at the PPO
negotiated rate when visiting a participating PPO dentist.
Nonpreferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular
geographic area.
Above list of covered services is representative. A summary of exclusions is listed later in this brochure. For a full list of benefit coverage and exclusions refer to the plan
documents.
All products not available in all counties.
This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general description of plan benefits or
programs and does not constitute a contract.
1-800-MY HEALTH | www.aetnaindividual.com
10
Aetna Advantage Plans include special programs
1
to complement our standard health insurance coverage.
These programs include health information programs and tools, and offer you access to substantial savings on products
to help you stay healthy. These programs are offered in addition to your Aetna Advantage Plan and are NOT insurance.
For more information on any of these programs, please visit us online at www.aetna.com.
Aetna Vision
SM
Discount Program
Aetna Vision
SM
discount program offers special savings on eye exams, contact lenses, frames, lenses,
LASIK eye surgery, and eye care accessories.
Aetna Natural Products and
Services
SM
Discount Program
Eligible Aetna members and their families can access complementary health care products and services at
reduced rates through the Aetna Natural Products and Services discount program. Members can save on
acupuncture, chiropractic care, massage therapy and dietetic counseling as well as on over-the-counter
vitamins, herbal and nutritional supplements and other health-related products.
Aetna Fitness
SM
Discount
Program
Eligible Aetna members and their families can access the GlobalFit™ national network of nearly 10,000
fitness clubs, in the United States and Canada, at preferred rates*. In addition, members can access other
programs such as at-home weight loss programs, home fitness options and even one-on-one health
coaching** services.
Aetna Weight Management
SM
Discount Program
The Weight Management
SM
discount program can help you achieve your weight loss goals by providing
you with a sensible weight loss plan and balanced nutrition guide to fit your lifestyle. This program
provides Aetna members and their eligible family members access to discounts on Jenny Craig
®
weight
loss programs and products.
Aetna Hearing
SM
Discount Program
Aetna’s Hearing
SM
discount program helps Aetna members and their families save on hearing exams,
hearing services and hearing aids.
Aetna Rx Home Delivery
®
With this mail order prescription drug program, order prescription medications through our
convenient and easy-to-use mail order pharmacy. To learn more or obtain order forms, visit
www.AetnaRxHomeDelivery.com.
Informed Health
®
Line
Our 24-hour toll-free number that puts you in touch with experienced registered nurses and an audio
library for information on thousands of health topics.
Aetna Navigator
®
Register and log on to Aetna Navigator, Aetna’s secure member website, to check claims status, contact
Aetna Member Services, estimate the costs of health care services, and more. Our new Aetna Navigator
Health Information Guide provides a starting point to find answers about health care, types of treatment,
cost of services and more to help members make more informed decisions. Plus, members have access
to their own Personal Health Record***, a single, secure place where they can view their medical history
and add other health information.
More value with
Aetna special programs
3)
Discount programs provide access to discounted prices and are NOT insured benefits.
1 Availability varies by plan. Talk with your Aetna representative for details.
* At some clubs, participation in this program may be restricted to new club members.
** Provided by WellCall, Inc. through GlobalFit.
*** The Aetna Personal Health Record should not be used as the sole source of information about your health conditions or medical treatment.
11
To qualify for an Aetna
Advantage Plan, you must be:
n
Under age 64 3/4 (If applying as a
couple, both you and your spouse
must be under 64 3/4.)
n
Dependents are covered up to age 24
n
Legal residents in a state with products
offered by the Aetna Advantage Plans
n
Legal U.S. residents for at least six
continuous months
Your premium payments
Your rates are guaranteed not to increase
for 12 months from your effective date once
you’ve been accepted for coverage. After
that, your premiums may change. Final rates
are subject to underwriting review.
Your coverage
Your coverage remains in effect as long
as you pay the required premium charges
on time, and as long as you maintain
eligibility in the plan. Coverage will be
terminated if you become ineligible due
to any of the following circumstances:
n
Non-payment of premiums
n
Becoming a resident of a state or
location in which Aetna Advantage
Plans are not available
n
Obtaining duplicate coverage
n
For other reasons permissible by law
Levels of coverage & enrollment
n
You may be enrolled in your selected
plan at the premium charge.
n
You may be enrolled in your selected plan
at a higher premium, based on medical
underwriting.
n
You may be declined coverage based on
medical underwriting.
Medical underwriting
requirements
The Aetna Advantage Plans are not
guaranteed issue plans and require medical
underwriting. Some individuals may qualify
as federally eligible under the Health
Insurance Portability Accountability Act
(HIPAA) through the Missouri Health
Insurance Pool (MHIP) program.
All applicants, enrolling spouses and
dependents are subject to medical
underwriting to determine eligibility and
appropriate premium rate level.
We offer various premium rate levels
based on the medical underwriting of
each applicant.
10-day right to review
Do not cancel your current insurance until
you are notified that you have been accepted
for coverage. We’ll review your enrollment
form to determine if you meet underwriting
requirements. If you’re denied, you’ll be notified
by mail. If you’re approved, you’ll be sent an
Aetna Advantage Plan contract and ID card.
If, after reviewing the contract, you find that
you’re not satisfied for any reason, simply
return the contract to us within 10 days.
We will refund any premium you’ve paid
(including any contract fees or other charges)
less the cost of any services paid on behalf of
you or any covered dependent.
Duplicate coverage
If you are currently covered by another carrier,
you must agree to discontinue the other
coverage before or on the effective date of
the Aetna Advantage Plan. Do not cancel your
current insurance until you are notified that
you have been accepted for coverage and
are certain that you are keeping your Aetna
Advantage Plan coverage.
Things you
need to know
EASY-PAY
Simple Automatic Payments via
Electronic Funds Transfer (EFT)
Registration: Complete the payment
section of the Aetna Advantage Plans
enrollment form. Select the EFT option
to approve the automatic withdrawal of
your initial premium and all subsequent
premium payments.
Invoices: You will not receive a paper
invoice when you are enrolled in EFT.
Payments will appear on your bank
statement as “Aetna Autodebit Coverage.”
Terminating: To terminate EFT, you will
need to provide Aetna with 10 days
written notice prior to the date your next
EFT payment will be deducted. Without
this written notice, your bank account may
be debited for the next month’s premium.
You will then need to contact Aetna to
have funds placed back in the checking
account.
Refunds: To process an EFT refund
(placing money back in member’s checking
account), Aetna will require at least five
days after the withdrawal was made to
ensure valid payment.
Rejected transactions: If the EFT
payment rejects for any reason, Aetna will
automatically terminate the EFT and send
you a letter saying you will receive paper
invoices. Processing time to reinstate EFT
will be 30–60 days. If an EFT payment is
rejected, you will need to pay that payment
by paper check or credit card.
Timing: Payments for Cycle 1 accounts
(1st of the month effective date) will be
taken from your bank account between
the 3rd and the 10th of the month the
premium is due. Payments for Cycle 2
accounts (15th of the month effective
date) will be taken from your bank
account between the 18th and 23rd of
the month the premium is due.
4)
1-800-MY HEALTH | www.aetnaindividual.com
12
Limitations & exclusions
Medical
These medical plans do not cover all health
care expenses and include exclusions and
limitations. You should refer to your plan
documents to determine which health care
services are covered and to what extent.
The following is a partial list of services
and supplies that are generally not covered.
However, your plan documents may contain
exceptions to this list based on state
mandates or the plan design or rider(s).
Services and supplies that are generally not
covered include, but are not limited to:
n
All medical and hospital services not
specifically covered in, or which are limited
or excluded by your plan documents,
including costs of services before coverage
begins and after coverage terminates
n
Ambulance coverage is limited to $1,000
per trip
n
Cosmetic surgery
n
Custodial care
n
Donor egg retrieval
n
Weight control services including surgical
procedures for the treatment of obesity,
medical treatment, and weight control/loss
programs
n
Experimental and investigational
procedures, (except for coverage for
medically necessary routine patient care
costs for Members participating in a cancer
clinical trial)
n
Charges in connection with pregnancy care
other than for pregnancy complications
n
Immunizations for travel or work
n
Implantable drugs and certain injectable
drugs including injectable infertility drugs
n
Infertility services including artificial
insemination and advanced reproductive
technologies such as IVF, ZIFT, GIFT,
ICSI and other related services unless
specifically listed as covered in your plan
documents
n
Non-medically necessary services or supplies
n
Orthotics
n
Over-the-counter medications and supplies
n
Radial keratotomy or related procedures
n
Reversal of sterilization
n
Services for the treatment of sexual
dysfunction or inadequacies including
therapy, supplies or counseling
n
Special or private duty nursing
n
Therapy or rehabilitation other than those
listed as covered in the plan documents
n
Mental health not covered except for
severe biologically based mental or nervous
disorders
n
Chemical dependency and substance
abuse not covered except for Drug and
Alcohol dependencies associated with
severe, biologically based mental or
nervous disorders
Dental
Listed below are some of the charges
and services for which these dental plans
do not provide coverage. For a complete
list of exclusions and limitations, refer to
plan documents.
n
Dental Services or supplies that are
primarily used to alter, improve or enhance
appearance. Negotiated rates for cosmetic
procedures available when a participating
dentist is accessed.
n
Experimental services, supplies or
procedures
n
Treatment of any jaw joint disorder, such
as temporomandibular joint disorder
n
Replacement of lost or stolen appliances
and certain damaged appliances
n
Services that Aetna defines as not
necessary for the diagnosis, care or
treatment of a condition involved
n
All other limitations and exclusions in
your plan documents
PRE-EXISTING CONDITIONS
During the first 12 months following your effective date of coverage, no coverage will be provided for the treatment
of a pre-existing condition unless you have prior creditable coverage.
A pre-existing condition is an illness, disease, physical condition, or injury for which medical advice, or treatment was
recommended or received and/or the use of prescription drugs of any kind within six months preceding the effective
date of coverage. Services or supplies for the treatment of a pre-existing condition are not covered for the first 12
months after the member’s effective date. If the member had continuous prior creditable coverage within the 63 days
immediately preceding the signature on the application and meets certain other requirements, then the pre-existing
condition exclusion of 12 months may not apply.
13
©2010 Aetna Inc.
AA.02.305.1-MO (1/10) B
If you need this material translated into another language, please call Member
Services at 1-866-565-1236.
Si usted necesita este material en otro lenguaje, por favor llame a Servicios al Miembro al
1-866-565-1236.
This material is for information only and is not an offer or invitation to contract. Plan features
and availability may vary by location. Plans may be subject to medical underwriting or other
restrictions. Rates and benefits may vary by location. Health/Dental insurance plans contain exclu-
sions and limitations. Investment services are independently offered by the HSA Administrator.
Providers are independent contractors and are not agents of Aetna. Provider participation may
change without notice. Aetna does not provide care or guarantee access to health services. Not
all health services are covered. See health insurance plan documents for a complete description of
benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change.
Aetna receives rebates from drug makers that may be taken into account in determining Aetna’s
Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered
prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy
subsidiary of Aetna Inc., that operates through mail order. Health information programs provide
general health information and are not a substitute for diagnosis or treatment by a physician or
other health care professional. Plan for Your Health is a public education program from Aetna and
The Financial Planning Association. Information is believed to be accurate as of production date,
however, it is subject to change.
The Vital Savings by Aetna
®
program (the “Program”) is not insurance.
The Program provides Members with access to discounted fees pursu-
ant to schedules negotiated by Aetna Life Insurance Company for the
Vital Savings by Aetna
®
discount program. The Program does not make
payments directly to the providers participating in the Program. Each
Member is obligated to pay for all services or products but will receive
a discount from the providers who have contracted with the Discount
Medical Plan Organization to participate in the Program. Aetna Life
Insurance Company, 151 Farmington Avenue, Hartford, CT 06156,
1-877-698-4825, is the Discount Medical Plan Organization.
For more information about Aetna plans, refer to www.aetna.com.
Want to save on dental expenses?
Vital Savings by Aetna
®
is a discount program that provides you with dental
savings. This is not insurance. Enrolling in the program will give you access
to a network of providers who have agreed to accept discounted rates for
services. To sign up today, visit www.vitalsavings.com or call 1-877-698-4825.
1-800-MY HEALTH | www.aetnaindividual.com
FPO FSC logo here
