Although a specific service may be listed as a covered benefit, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition. Refer to the Key Terms section for the definition of medically necessary.

Certain services must be pre-certified by Aetna. Your in-network provider is responsible for obtaining this approval.

Preventive care

Preventive care services will be covered at 100%.  

Routine physical exams

Eligible health services include office visits to your PCP and/or Obstetrician/Gynecologist for routine physical exams.

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 (USPSTF).
• 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:

• Interpersonal and domestic violence
• Sexually transmitted diseases
• 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

• 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 for infectious diseases recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

Immunizations/vaccinations obtained outside of a physician's office or hospital:

Some immunizations can also be obtained or administered at participating retail pharmacies, using the Aetna ID card at an Aetna network pharmacy, or the Express Scripts ID card at an Express Scripts network pharmacy.

During the emergency period, the ExxonMobil Medical Plan has covered COVID-19 vaccines/boosters at no cost to members. Starting May 12, 2023, these will be included as a preventive vaccine (such as the annual flu shot), which are also available to members at no cost only when using in-network providers.

Well woman preventive visits

Eligible health services include your routine:

• Well woman preventive exam office visit to a network 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.
• Screening for diabetes after pregnancy for women with a history of diabetes during pregnancy.
• Screening for urinary incontinence.

Preventive screening and counseling services

Eligible health services include screening and counseling by  a network PCP 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.

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
• Double contrast barium enemas (DCBE)
• Colonoscopies which include 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 provider who is an OB, GYN or OB/GYN.

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

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

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. The plan will cover this counseling only 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. Contact Aetna for additional details.

Family planning services – female contraceptives

Eligible health services include family planning services such as:

• Counseling services: provided by a physician, PCP, OB, GYN, or OB/GYN on contraceptive methods.
• Devices: contraceptive devices (including any related services or supplies) when they are provided by, administered, or removed by a physician during an office visit.
• Voluntary sterilization: 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.

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 subject to the appropriate coinsurance.

Please note that the list above is not all inclusive, so for more information on the most updated preventive services, please refer to the following sites:

https://www.hhs.gov/healthcare/about-the-aca/preventive-care/index.html

https://www.healthcare.gov/coverage/preventive-care-benefits/

Physicians and other health professionals

Physician services

Physician services include: non-routine office visits with  aa network PCP during both office and non-office hours - including Telemedicine, non-routine home visits by a network  a PCP, treatment for illness and injury and injections, including routine allergy desensitization injections at PCP's office, with or without physician encounter. All, subject to copay.

Telemedicine

Telemedicine services are available via phone, web, or mobile app, 24 hours/day, 7 days/week through the Plan’s designated service provider (Teladoc). Teladoc’s health care professionals can evaluate, diagnose, and treat non-emergency medical and behavioral health conditions, such as cold/flu symptoms, stomach aches, common childhood illnesses, dermatology support, depression, stress, and anxiety. To register for services, call 855-835-2362 or visit www.Teladoc.com/Aetna.

Hospital and other facility care

Hospital care

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

• Room and board charge up to the hospital’s semi-private room rate.
• 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.

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.

Home health care

Eligible health services include home health care provided by a home health care agency in the home, but only when all of the following criteria are met:

• 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.

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.

Outpatient private duty nursing

Eligible health services include private duty nursing care provided by an R.N. or L.P.N. for non-hospitalized acute illness or injury if your condition requires skilled nursing care and visiting nursing care is not adequate.

Residential Treatment facility

This is an institution that:

• Specializes in the treatment of psychological and social disturbances that are the result of mental health or substance abuse conditions;
• Provides a sub-acute, structured, psychotherapeutic treatment program under the supervision of physicians;
• Provides 24-hour care, in which the patient lives in an open setting; and
• Is licensed as a residential treatment center in accordance with the laws of the appropriate legally authorized agency.

Skilled-nursing care

Skilled-nursing care is covered if medically necessary. Nursing care that helps a person meet personal needs and daily living activities, such as bathing, dressing, eating, or administering oral medication, even if ordered by a physician and performed by a licensed medical professional, is considered custodial and is not a covered expense eligible for benefits. Also, charges for a private-duty nurse in a hospital or an extended-care facility are not covered.

Skilled nursing facility

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

Skilled care

Skilled care involves nursing or rehabilitation services that can be provided only by licensed medical professionals. For example, intravenous feeding is a skilled service.

Emergency services and urgent care

Emergency care while traveling for business or a personal vacation:

If you require emergency medical care while traveling for business or a personal vacation, the Plan will cover your emergency treatment 24 hours a day, 7 days a week, anywhere in the world. 

Covered expenses are subject to the Plan’s applicable coinsurance, and copays.

If you are traveling outside the United States, unless you have made other arrangements with the emergency medical providers, you will be required to pay the medical bills and then submit the claims to Aetna for reimbursement. The ExxonMobil Plans do not directly reimburse medical providers located outside the United States.

For reimbursement, submit the itemized bills along with a claim form. If the original bills are in a foreign language, you should obtain an English translation if possible. Bills must be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars as of the date of service.

Follow-up care after emergencies

You must have approval from Aetna to receive follow-up care from a non network provider. Suture removal, cast removal, X-rays, and clinic and emergency room revisits are some examples of follow-up care.

Urgent care

Treatment that you obtain outside of your service area for an urgent medical condition is covered if:

• The service is a covered benefit,
• You could not reasonably have anticipated the need for the care prior to leaving the network service area, and
• A delay in receiving care until you could return and obtain care from a participating network provider would have caused serious deterioration in your health.

Aetna has adopted the following definition of urgent medical condition:

Urgent medical condition – means a medical condition for which care is medically necessary and immediately required because of unforeseen illness, injury, or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through your home service area or from  a network PCP.

Some examples of urgent medical conditions are:

• Severe vomiting,
• Earaches,
• Sore throat, or
• Fever.

Follow-up care provided by aa network PCP is covered, subject to the office visit copayment. Other follow-up care by participating specialists is subject to the specialist copay shown in the Benefits schedule.  If you are in your service area, you must use an in-network urgent care center.

Telemedicine services

Telemedicine services are available through the designated service provider (Teladoc) for non-emergency medical and behavioral health conditions such as cold/flu symptoms, stomach aches, common childhood illnesses, dermatology support, depression, stress, and anxiety. Services are available 24/7 via phone or video chat. You pay a primary care visit copayment each time you use the service. Call 1-855-Teladoc (835-2362) or visit Teladoc.com/Aetna.

What to do outside your Aetna service area

Emergency care

If a participant goes to a hospital emergency room for an Emergency Medical Condition, any medical provider can be utilized and the emergency room copay will apply.

Urgent care

For urgent care, if you are out of your service area, participants can use a non-network urgent care provider or go to an emergency room.  Non-emergency or non-urgent use of an urgent care provider is not covered.  Urgent care may be obtained from a walk-in clinic, or an urgent care center.  An urgent medical condition that occurs outside your Aetna service area can be treated in any of the above settings.

• If, after reviewing information submitted to Aetna by the provider(s) who supplied your care, the nature of the urgent or emergency problem does not clearly qualify for coverage, it may be necessary to provide additional information.

Although the Aetna Select is a network only plan option, if you receive emergency services out-of-network, the out-of-network provider exceptions below will apply.

Protections against surprise bills: out-of-Network Provider Exceptions

Services rendered by a non-Participating Provider are subject to special payment rules described below when:

1. You receive emergency services for an Emergency Medical Condition.
2. You receive services by a non-Participating Provider in an In-Network facility.
3. You receive covered air ambulance services.

Specifically, Covered Expenses rendered by a non-Participating Provider are generally paid at the “Surprise Billing Reimbursement Rate” (i.e., a rate calculated in accordance with ERISA § 716) when:

1. You receive emergency services for an Emergency Medical Condition. In this case, the cost share will be based on the recognized amount calculated in accordance with ERISA § 716. The cost share will not be greater than the amount that would have been charged if such services were provided by an In-Network Provider. If you receive these services, the Out-of-Network Providers cannot Balance Bill you.
2. You receive certain items and services by an out-of-Network Provider in an In-Network facility. In this case, the cost share will generally be based on the recognized amount calculated in accordance with ERISA § 716. The cost share will generally not be greater than the amount that would have been charged if such services were provided by an In-Network Provider. If you receive these services, the out-of-Network Providers cannot Balance Bill you, unless you give written consent.
1. You receive covered air ambulance services. In this case, the cost sharing will be based on the lesser of the qualifying payment amount (calculated in accordance with ERISA § 716) or the billed amount for the services. The cost share requirements will be the same requirements that would apply if the services were provided by an In-Network Provider of air ambulance services. If you receive these services, the out-of-Network Providers cannot Balance Bill you.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or you’re treated by an out-of-network provider at an in-network hospital, or ambulatory surgical center or by an air ambulance provider, you are protected from surprise billing or Balance Billing.

For more information on your rights, please refer to the Surprise Medical Bills notice located in exxonmobilfamily.com

When Balance Billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost, such as the copayments and coinsurance, that you would pay if the provider or facility was in-network. Your health plan will pay out-of-network providers and facilities directly.
• You’re never required to give up your protections from balance billing. You also don’t have to get care out-of-network. You can choose a provider or facility in your plan’s network.

  You are protected from Balance Billing for:

  Emergency services
  • If you have an Emergency Medical Condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount. This includes copayments and coinsurance. You can’t be Balance Billed for these emergency services. This includes services you may get after you’re in stable condition. The exception is if you give written consent and give up your protections not to be Balanced Billed for these post-stabilization services.

     

  • Certain services performed by an out of network provider at an in-network hospital or ambulatory surgical center
    When you get services from certain out-of-network providers at an in-network hospital or ambulatory surgical center, those out-of-network providers may not Balance Bill you or ask you to sign a written notice and consent form that allows Balance Billing. You pay only your plan’s in-network cost sharing amount. This applies to anesthesia, assistant surgeon, emergency medicine, hospitalist, intensivist service, laboratory, neonatology, pathology, or radiology.
    
    If you get other services from any other out-of-network providers at in-network hospital or ambulatory surgical center, these out-of-network providers can’t Balance Bill you, unless you sign a written notice and consent form that allows Balance Billing and are provided with a good faith estimate of your costs from the hospital or ambulatory surgical center before services are given. If you sign the notice and consent form, you can be Balance Billed for out-of-network services. You are not required to sign the notice and consent form. You may seek care from an available in-network provider.
   
  Air Ambulance
  • When you receive medically necessary air ambulance services from an out-of-network provider, your cost share will be the same amount that you would pay if the service was provided by an in-network provider.  Any cost sharing will be based on rates that would apply if the services were supplied by an in-network provider.
  • Some states have surprise bill/balance billing laws.  These laws apply to fully insured plans and may have impact to some self-funded plans, including state government or municipal plans and church plans.

Your health plan generally must:

• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your out-of-pocket limit.

How to handle services supplied based on inaccurate provider directory information?

If you relied on inaccurate information from our provider directories or website or that we verbally provided, we hold you harmless. For example, if you received services from a provider that you believed was in-network based on inaccurate information showing that the provider was in-network, but your claim was paid as out-of-network. In these situations, contact us and we will review the claim. After review, you may be responsible only for your in-network cost share.

Specific conditions

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.

Applied Behavior Analysis (ABA) will be covered consistent with Aetna´s clinical policy bulletins..

Coverage does not include services for custodial care, educational services, or services performed in an academic, vocational or recreational setting.

Fertility Services

Fertility services will be covered, when services are authorized by Progyny, the Plan’s designated Fertility Services Network Organization.

Covered services include comprehensive fertility treatment, Advanced Reproductive Technology (ART), ovulation induction, donor tissue purchase and cryopreservation services, as well as member support services and digital tools, for up to three “smart cycles” or episodes of care (four cycles if required for the first pregnancy) as defined by Progyny and when obtained at a Progyny network provider. Contact Progyny at 1-833-851-2229 to initiate services.

Examples of how a Smart Cycle can be used:

• Egg Freezing = ½ Smart Cycle
• Frozen Embryo Transfer (FET) = ¼ Smart Cycle
• Frozen Oocyte Transfer (FOT) = ½ Smart Cycle
• Intrauterine Insemination (IUI) or Timed Intercourse (TIC) = ¼ Smart Cycle
• In Vitro Fertilization (IVF) Fresh Cycle or IVF Freeze-All Cycle = ¾ Smart Cycle
• Sperm Freezing = ¼ Smart Cycle
• Surrogacy Embryology Services (pre-transfer) = ½ Smart Cycle

Notes: Claims related to diagnosis and treatment of the underlying conditions during your treatment with Progyny will continue to be filed through Aetna.

Dependent children are not eligible for fertility services.

Family planning services – other

Eligible health services include certain family planning services provided by your physician such as voluntary sterilization for males.

Gender affirming surgery

Gender affirming surgery is considered medically necessary when certain criteria are met. Please refer to Aetna’s Clinical Policy Bulletins for more information about the criteria relating to gender affirming surgery.

Insulin and diabetic supplies

Insulin and diabetic supplies are covered under the prescription drug plan through Express Scripts.  They can be obtained through a retail pharmacy or through home delivery by paying your required coinsurance.  In those rare instances where insulin or diabetic supplies are received in a doctor’s office, outpatient facility or hospital setting, they are covered as a medical expense.

Maternity and related newborn care

Eligible health services include prenatal and postpartum care and obstetrical services related to the pregnancy of a covered child, but not those related to the child born to the family member.

After your child is born, eligible health services include:

• 48 hours of inpatient care in a hospital after a vaginal delivery
• 96 hours of inpatient care in a hospital after a cesarean delivery
• A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn earlier

Oral and maxillofacial treatment (mouth, jaws and teeth)

Covered services include the following when provided by a physician, dentist and hospital:

• Dental work required by an accidental injury to sound, natural teeth or the mouth
• Cutting out:

• Cysts, tumors, or other diseased tissues

• Cutting into gums and tissues of the mouth.

• Only when not associated with the removal, replacement or repair of teeth

Reconstructive surgery and supplies

Eligible health services include all stages of 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, treatment of physical complications of all stages of the mastectomy, including lymphedema and prostheses.
• Your surgery is to implant or attach a covered prosthetic device.
• Your surgery corrects a gross anatomical defect present at birth. The surgery will be covered if:

• The defect results in severe facial disfigurement or major functional impairment of a body part.
• The purpose of the surgery is to improve function.

• Your surgery is needed because treatment of your illness resulted in severe facial disfigurement or major functional impairment of a body part, and your surgery will improve function.

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Transplant services

Eligible health services include transplant services provided by a physician and hospital.

This includes the following transplant types:

• Solid organ
• Hematopoietic stem cell
• Bone marrow
• CAR-T and T-Cell receptor therapy for FDA approved treatments

Network of transplant 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 Excellence™ (IOE) facility we designate to perform the transplant you need
• A Non-IOE facility

Your cost share will be lower when you get transplant services from the IOE facility we designate to perform the transplant you need. You may also get transplant services at a non-IOE facility, but your cost share will be higher.

The National Medical Excellence Program® will coordinate all solid organ, bone marrow and CAR-T and T-Cell therapy services and other specialized care you need.

Important note: If there is no IOE facility for your transplant type in your network, the National Medical Excellence Program® (NME) will arrange for and coordinate your care at an IOE facility in another one of our networks.  If you don’t get your transplant services at the IOE facility we designate, your cost share will be higher.

Many pre and post-transplant medical services, even routine ones, are related to and may affect the success of your transplant. While your transplant care is being coordinated by the NME Program, all medical services must be managed through NME so that you receive the highest level of benefits at the appropriate facility. This is true even if the covered service is not directly related to your transplant.

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

Complex imaging for preoperative testing is covered under this benefit.  Some services may require precertification.

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.

COVID-19 diagnostic tests (both administered in doctor’s offices or at pharmacies) and over-the-counter (OTC) COVID-19 tests have been covered by the Plan during the emergency period. Starting May 12, 2023, COVID-19 tests performed in doctor’s offices or at a pharmacy will be covered at the appropriate cost share for diagnostic tests.  Please see the Benefit Summary for detailed information on cost share for diagnostic tests.  

Starting May 12, 2023, COVID-19 OTC tests will not be covered at point of sale, but members that participate in the Health Care Flexible Spending Account (HC FSA) may request reimbursement for those tests, as long as they are considered eligible medical expenses. Inclusion of COVID-19 OTC tests as an eligible HC FSA expense is subject to IRS guidance, which may change in the future.

Chemotherapy

Eligible health services for chemotherapy depends 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.

Chelation therapy

Chelation therapy is covered when considered medically necessary in the treatment of any of the diseases/disorders listed in Aetna Coverage Policy Bulletins.

Oral-motor therapy

Oral-motor therapy is covered when considered medically necessary in the treatment of any of the diseases/disorders listed in Aetna Coverage Policy Bulletins.

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 the office or a home care provider in your home.

Outpatient radiation therapy

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

• Cardiac rehabilitation: includes 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: includes pulmonary rehabilitation services as part of your inpatient hospital stay if it 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.

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 the activities of daily living.

• Speech therapy, but only if it is expected to:

• Significantly improve or restore the speech function or correct a speech impairment as a result of an acute illness, injury or surgical procedures.
• Improve delays in speech function development caused by a gross anatomical defect present at birth.

• 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.

If you or your provider anticipates that your current course of therapy may exceed 25 visits, have your physician or therapist submit medical records with each physical therapy claim. Claims for therapy service beyond the 25^th visit are subject to medical review. Additional information will be required. Claims will not be paid if the service is found not to be medically necessary or rendered in connection with an IEP (Individualized Education Program) in a school setting. Visit limits do not apply to behavioral health services.

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). The plan standardly covers rehabilitation and habilitation services, as long as the services aren’t considered experimental and investigational.

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 (except for services provided in an educational or training setting), 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.
• Speech therapy (except for services provided in an educational or training setting or to teach sign language) is covered provided the therapy is to:
• Restore speech after a demonstrated previous ability to speak is lost or impaired,
• Improve or develop speech after surgery to correct a birth defect which impaired or would have impaired the ability to speak, or
• Improve, develop, or maintain speech impaired as a result of delayed development, including autism spectrum disorder, down syndrome, cerebral palsy, fetal alcohol syndrome, and muscular dystrophy. Submission of a proposed treatment plan for a benefit predetermination is strongly recommended.)

Other services

Acupuncture

Eligible health services include manual or electro acupuncture consistent with Aetna Coverage Policy Bulletins.  Limited to a 10-visit maximum per year.

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 a 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 services you need, and
• The two conditions above are met.

Chiropractic services

Chiropractic services will be covered only when performed by a licensed doctor or chiropractic who is acting within the scope of his or her license, limited to a 20-visit annual maximum.

Clinical Trials

Eligible health services include routine patient costs otherwise covered by the Plan that are associated with participation in phases I-IV of Approved Clinical Trials (as further defined in  Key Terms) (i.e., clinical trials that are federally funded and certain drug trials) to treat cancer or other Life-Threatening Conditions, as determined by Aetna and as required by law. These costs will be subject to the Plan’s otherwise applicable cost-sharing requirements and limitations and do not include items that are provided for data collection or services that are clearly inconsistent with widely accepted and established standards of care or otherwise payable or reimbursable by another party.

Durable medical equipment (DME)

Durable medical equipment (DME) when medically necessary, prescribed by a physician for the treatment of an illness or injury. Some DME may require preauthorization from Aetna. For more information on precertification, see the National Precertification List on the Aetna member website. Replacement, repair and maintenance are only covered for purchased DME if:   

• It cannot be repaired
• Repairs would be more expensive than purchasing or renting replacement equipment   
• The attending physician recommends replacement because of a change in the patient’s physical condition   

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 exclusions section.

Extended-care facilities

An extended-care facility provides skilled-nursing services and rehabilitation care. Extended-care facility charges are covered expenses if these conditions are met:

• The inpatient stay must be Medically Necessary, and
• The inpatient stay has been pre-certified.

Reimbursement is based on the facility charge or daily room and board rate of the hospital from which the patient transferred, whichever is less.

Gene Therapy Benefits

For certain gene therapy medications, the Embarc Gene Therapy Protection program allows members to receive life-changing medications with no out of pocket drug costs. As of January 1, 2023, included medications are Luxturna®️, Zolgensma®️, Zynteglo®️, Skysona®️ and Hemgenix®️. Express Scripts will be performing the prior authorization requests and your clinician can request a review as needed by contacting Express Scripts at 1-800-753-2851. Additional medications may be added pending FDA approval and program changes.

Cost share for associated medical claims, i.e. related inpatient stays, would still apply. Due to the rare nature of these medications and limited network access, medical claims associated with the administration of an Express Scripts-authorized gene therapy medication will be considered non-volitional, which means they will be covered and adjudicated at the in-network level.

Questions about medical claims should still be directed to Aetna.

Non-routine/non-preventive care hearing exams

Eligible health services for adults and children include charges for an audiometric hearing exam for evaluation and treatment of illness, injury or hearing loss, if the exam is performed by:

• A physician certified as an otolaryngologist or otologist
• An audiologist who is legally qualified in audiology; or holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association (in the absence of any applicable licensing requirements); and who performs the exam at the written direction of a legally qualified otolaryngologist or otologist.

Prosthetic devices

Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the purchase price.

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

Behavioral health and substance use disorder care

Behavioral Health coverage

Covered services include the treatment of behavioral health disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider including:

• Inpatient room and board at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), 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)
  • Individual, group, and family therapies for the treatment of behavioral health disorders
  • Other outpatient behavioral health treatment such as:
    • Partial hospitalization treatment provided in a facility or program for behavioral health treatment provided under the direction of a physician
      • Intensive outpatient program provided in a facility or program for behavioral health treatment provided under the direction of a physician
      • Skilled behavioral health services provided in the home, but only when all of the following criteria are met:
        • You are homebound
        • Your physician orders them
        • The services take the place of a stay in a hospital or a residential treatment facility, or you are unable to receive the same services outside your home
        • The skilled behavioral health care is appropriate for the active treatment of a condition, illness, or disease
      • Electro-convulsive therapy (ECT)
      • Transcranial magnetic stimulation (TMS)
      • Psychological testing
      • Neuropsychological testing
      • Observation
      • Peer counseling support by a peer support specialist

Substance use disorder treatment

Covered services include the treatment of substance related disorders 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 (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies 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 psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)
  • Individual, group, and family therapies for the treatment of substance related disorders
• Other outpatient substance related disorders treatment such as:
  • Partial hospitalization treatment provided in a facility or program for treatment of substance related disorders provided under the direction of a physician
  • Intensive outpatient program provided in a facility or program for treatment of substance related disorders provided under the direction of a physician
  • Ambulatory or outpatient detoxification which include outpatient services that monitor withdrawal from alcohol or other substances, including administration of medications

• Observation
• Peer counseling support by a peer support specialist

Behavioral health important note:

A peer support specialist serves as a role model, mentor, coach, and advocate. They must be certified by the state where the services are provided or a private certifying organization recognized by Aetna. Peer support must be supervised by a behavioral health provider.