About the Medical Plan

Eligibility and Enrollment

The Prescription Drug Program

Mental Health and Chemical Dependency Care

Covered Expenses

Exclusions

Payments

Claims

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

Basic Plan Features

Q. What are the basic features of the POS II options?

A. The basic features of the POS II options are:

• The Plan generally covers only medically necessary care and services.
• Inpatient hospital stays must be pre-certified for maximum benefit allowed by the Plan.
• The Medical POS II network of participating providers offers you savings in both time and money.
• Preventive care provisions help you stay healthy.
• The Plan offers you the opportunity to have your benefits determined before a procedure is performed.

Both POS II options include the features listed below.

Medically Necessary

Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that experimental or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See page 42 for limited exceptions.

When determining medical necessity, the Administrator-Benefits may consider the Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator. CPBs are based on established, nationally accepted governmental and/or professional society recommendations, as well as other recognized sources. These CPBs may be found on the Aetna Web site at www.aetna.com or the Aetna Navigator^TM Web site at www.aetnanavigator.com.

Pre-Certification/Pre-Determination

Generally, a hospital stay must be pre-certified before you are admitted. See the Information Sources section at the front of this SPD for the telephone numbers. However, there are other services that require pre-certification as listed on the next page.

Pre-certification should be obtained prior to any hospital inpatient stay (including mental health and chemical dependency) to give notice of inpatient admission and the proposed care. The following outlines services that need to be pre-certified.  If you are unsure if the service you are seeking requires pre-certification, call Aetna Member Services.

For Non-Emergency Medical Care:

• Hospitalization
  • If you are using a POS II network provider, or a mental health PPO network provider, your provider will handle the pre-certification process for you. 
  • Before you are admitted to a hospital that does not participate in the POS II or mental health PPO network, you must call Aetna for a medical pre-admission review or Magellan for a mental health confinement. This is required for most inpatient admissions, including extended-care facilities. 
  • You are not required to call to pre-certify: 
    • Hospitalization outside the United States, for both medical and mental health or substance abuse; or 
    • Outpatient surgery, even if performed in a hospital.
• Durable medical equipment
  • In order to maximize your benefits for the purchase or repair of durable medical equipment, call Aetna Member Services to locate a network provider or to obtain a pre-determination (recommended for any durable medical equipment). You should also verify with Aetna Member Services whether a pre-certification is required for the purchase or repair of durable medical equipment. For example, a power wheelchair requires a pre-certfication.
• Hospice care.
• Extended care facility.
• Skilled nursing care.
• Home health care.
• Private duty nursing.

Benefit Pre-Determinations
You can call Aetna Member Services to determine in advance whether a particular treatment or service is covered under your POS II option and whether the proposed cost is within reasonable and customary limits for out of network providers. See the Information Sources section at the front of this SPD.

In most cases, you may receive an answer over the phone. In other cases, information from your provider may be needed. You or your doctor can also request a pre-determination of benefits, in writing, before the service is performed.

This pre-determination may require review by one or more doctors. Be sure to allow time for this review between the pre-determination request and the proposed date of the service. By obtaining the written response, you will have more detailed information about the level of reimbursement.

When you call for a benefit pre-determination, be ready to provide the following information:

• Primary participant's name and Social Security number or ID number;
• Patient's name;

• Complete description of medical services or surgical procedures. If possible, include the diagnosis code(s) and the five-digit Current Procedural Terminology (CPT) codes, which you can get from the provider;
• Provider's ZIP code; and
• Provider's proposed fee for each service.

For Emergency Medical Care:
Certification must be made within 48 hours following an emergency inpatient admission. If the admission is on a weekend or holiday, notification must be made within 72 hours.

• If you are using a POS II network provider, your provider will obtain certification for you.
• You or someone acting on your behalf must call to certify care if you are in a non-network or out-of-network area hospital.

For Mental Health or Chemical Dependency Care:
You should call Magellan Behavioral Health for pre-certification of any mental health or chemical dependency care. This applies whether you are inside or outside the United States.

The Aetna POS II network is not used for mental health or chemical dependency care. Contact Magellan Behavioral Health for network information and pre-certification of mental health or chemical dependency care. See the Information Sources section on page 1.

If you require mental health or chemical dependency care in conjunction with a medical emergency, you must notify Magellan within the appropriate time periods described on page 33.

For Certain Prescription Drugs: 
You must call Medco for pre-certification of certain prescription drugs. This applies whether you are inside or outside the United States.

In the therapeutic chapters listed below, there will be targeted drugs determined by Medco which will not be covered unless pre-certified by Medco. Non-targeted drugs will be covered without such authorization, and will continue to be dispensed with no further action by either a participant or the prescribing physician. These classes are proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, and growth hormone. Additional prior authorization rules apply to certain therapeutic chapters of drugs; miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. Certain drugs within each chapter as determined by Medco will only be covered to the extent they are authorized by Medco. If you have a question regarding a drug in any of these therapeutic chapters, contact Medco to determine whether your drug is covered without pre-certification.

About Pregnancy

Federal law mandates that benefit programs such as the Medical Plan cover eligible participants for a minimum length of stay for delivery and newborn hospitalizations. Those minimums are 48 hours following a vaginal delivery and 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). 

Medical POS II Network

The network includes a group of physicians, hospitals, and other providers who have met standards for licensing, academic background and service. If you use network providers, the Plan pays a larger portion of the covered expenses. Network providers have agreed to negotiated charges which may save you and the plan money. Other advantages to using Medical POS II network providers for medical care are:

• Most office visits, diagnostic laboratory and X-ray work are reimbursed at 100%, unless related to emergency room, in-patient hospital, outpatient surgery or complex imaging are provided for a small, fixed co-payment and you do not have to meet the annual deductible.
• Other covered expenses from network providers are reimbursed at the network reimbursement level (either 80% for the POS II "B" or 75% for the POS II "A") of a negotiated rate after you meet the annual deductible.
• Your annual out-of-pocket maximum is significantly lower.
• Medical POS II network providers file claims and handle the hospital pre-admission review process for you.
• All negotiated charges are within reasonable and customary limits (see definition on page 45).

Network Locations
Medical POS II networks are located throughout the United States. As explained on page 4, the Medical POS II is part of the Aetna Choice^® POS II network.

You are a network participant if you live in a Medical POS II area. These are some of the Medical POS II areas:

If you or an eligible family member resides in a network area, you can use Aetna's Internet DocFind^® (www.aetna.com/docfind) to locate providers in the area. ExxonMobil Me, the HR Intranet site, has a ZIP code search tool that identifies whether your home address ZIP code is located in an Aetna network area or in an out-of-network area.

Benefits Based on the Network Status of the Provider
Generally, you will receive network benefits only if the provider is in the Medical POS II network.  This applies whether or not the care is received in a network area or in an out-of-network area.

To Find an Aetna Choice^® POS II Provider:

• Check DocFind^® (www.aetna.com/docfind) on Aetna's Web site for the most up-to-date list of Choice^® POS II providers. The site is updated three times a week.
• Call Aetna Member Services for help with locating a POS II network provider.

Before your appointment, confirm with Aetna Member Services and/or the doctor's office whether the doctor participates in the network, because network participation may change.

Co-Payment for Office Visits/Lab Work when provided by a primary care physician; higher co-payment when provided by a specialist.
When you use Medical POS II network providers for routine office visits, you are not subject to the annual deductible. You pay a co-payment for each routine office visit, including most related lab work and radiology performed by a POS II network provider.

A co-payment does not apply to more extensive tests, including complex imaging (i.e., CT scans, MRI, MRA, PET/SPECT), radiopharmaceutical stress tests, angiography myelography, MUGA scans and sleep studies, which are subject to the deductible and co-insurance.

If an injection (other than an injection into a vein or artery) is received in a network doctor's office without an office visit, the co-payment will be the actual cost of the injection or the office visit co-payment, whichever is less. For infusion therapy and chemotherapy, a fixed co-payment only applies to the office visit. All other related services are paid at the percentage co-payment. Allergy serum dispensed by a network doctor for at home use is reimbursed at the network reimbursement level after the deductible.

These co-payments do not apply to your deductible but do apply to your annual out-of-pocket limit. See the explanation beginning on page 44 for more information about deductibles and co-payments.

Is Your Doctor a Network Provider?
Call your doctor's office to confirm his or her participation in the Aetna Choice^® POS II network. If your doctor is not participating, ask him or her to consider applying to participate. Your doctor can obtain information about becoming a network participant from Aetna's Web site (www.aetna.com/healthcare-professionals/index.html) or by calling Aetna Credentialing Customer Service at 1-800-353-1232.

If an Aetna Choice POS II network provider is not available within your access area, you may contact Aetna Member Services for information regarding the Plan's alternative network deficiency benefit.  The alternate benefit is designed to address any network deficiency situations.

Show Your ID Card
When you visit a physician or other health care provider, present your Medical Plan identification card. This helps the provider confirm your eligibility and understand your benefits coverage.

If You Live in a Medical POS II Network Area and Do Not Use Medical POS II Network Providers
When you use non-network providers:

• Your out-of-pocket costs will generally be higher. The Plan's reimbursement level is 60% for the POS II "B" and 55% for the POS II "A" of reasonable and customary charges, after you satisfy the deductible.
• You must call Aetna to initiate the medical pre-admission review process for inpatient treatment.
• If your provider's charges are above reasonable and customary limits, you are responsible for paying any amounts above reasonable and customary limits.
• You are responsible for submitting claims.

Emergency Care
Go to the nearest hospital for treatment. Benefits for emergency care (as a result of emergency outpatient treatment or an emergency admission to a hospital following emergency outpatient treatment received at the same hospital) are paid at the network reimbursement level for both network and non-network providers. However, the network reimbursement level for emergency care by non-network providers is only payable until the patient is determined able to be safely transferred to a network facility.

Emergency services from non-network providers are limited to reasonable and customary amounts, except those for radiology, pathology, anesthesiology, ambulance or emergency room physician services. 

When you go to the emergency room, you are subject to a deductible. If you are admitted as an inpatient to the hospital following emergency outpatient hospital treatment, the deductible amount will apply to your separate inpatient hospital deductible. See pages 80-85.

Urgent Care
Your physician may direct you to an Urgent Care Center as an alternative to a hospital emergency room when he or she feels it is appropriate to do so. If you or a family member receive care at a network urgent care center, you will pay the applicable co-pay, equal to the specialist physician co-pay under your plan option, and the plan pays the remaining charges.  If you live in a network area, and you use a non-network urgent care center, you will be reimbursed at the non-network level (either 60% for the POS II "B" or 55% for the POS II "A"), after the plan year deductible has been satisfied.  If you live in an out of network area, you will be reimbursed at the out of network area level (either 80% for the POS II "B" or 75% for the POS II "A") after you have met your deductible.

Care While Traveling
For non-emergency care, call Aetna Member Services to identify a nearby POS II network provider or check DocFind on Aetna 's Web site (www.aetna.com/docfind).

If You Live Outside a Medical POS II Network Area
If you live outside a Medical POS II network area, you are considered to be in an out-of-network area and you will be reimbursed at 80% for the POS II "B" and 75% for the POS II "A" of reasonable and customary charges when you use a non-network provider for services other than those listed under Emergency Care. In addition, you must satisfy the deductible for all covered services other than preventive care. You are responsible for initiating the medical pre-admission review process for inpatient treatment unless you use a network provider.

Even though you may not live in a Medical POS II network area, you may live in or near locations where there are Medical POS II providers. If you receive care from an Aetna Choice^® POS II network provider — even while traveling — you will receive network reimbursement and network co-payments will apply.

If a Covered Family Member Lives Away from Home
If you live in a Medical POS II network area and you have a covered family member who lives away from home (for instance, you have a child away at school), your family member's ZIP code determines the level of benefits the Plan pays.

Call Aetna Member Services with your family member's ZIP code to find out if Aetna has a Choice® POS II network in the area. If a network is there, you can contact Aetna Member Services or use the Internet DocFind to identify providers in the area. Here is how benefits are determined:

• If your family member receives care from a network provider, benefits will be paid at the network level.
• If your family member lives in a Medical POS II network area but uses non-network providers, benefits are paid at the non-network level.
• If your family member lives in an area where the Medical POS II network is not available and receives care from a non-network provider, benefits are paid at the out-of-network area level — regardless of whether you live in a network or non-network area — if you have notified Aetna of your family member's address.

Upon request, Aetna Member Services will provide an identification card for your family member.

Preventive Care
Certain preventive care services will be covered at 100%. If you use a non-network provider or live in a location where there is not a Medical POS II network, reasonable and customary charges for covered preventive care services will continue to apply. Preventive care services covered at 100% include the following:

• Immunizations
• PSA/DRE (Prostate Screening)
• Routine Adult Physical
• Routine Mammography
• Routine GYN Exam
• Routine Well Baby Exam (includes hearing exam if under age 7)
• Routine Well Child Exam (includes hearing exam if under age 7)
• Colorectal Cancer Screening
  • Double Barium Enema
  • Fecal Occult
  • Sigmoidoscopies
  • Colonoscopy

To receive preventive care benefits, the doctor's bill must indicate that the service is preventive in nature. If you are found to have a condition requiring additional treatment, the additional covered services will be paid after you meet any remaining annual deductible.