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 participating provider is responsible for obtaining this approval.
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.
- 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.
Well woman preventive visits
Eligible health services include your routine:
- Well woman preventive exam office visit to your 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 your 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:
- Prostate specific antigen (PSA) tests
- Digital rectal exams
- Fecal occult blood tests
- Double contrast barium enemas (DCBE)
- Colonoscopies which includes removal of polyps performed during a screening procedure, and a pathology exam on any removed polyps
- Lung cancer screenings
These benefits will be subject to any age, family history and frequency guidelines that are:
- Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force
- Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration
If you need a routine gynecological exam performed as part of a cancer screening, you may go directly to a network provider who is an OB, GYN or OB/GYN.
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 your 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 paid after you meet any remaining annual deductible.
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:
Physicians and other health professionals
Physician services include: non-routine office visits with your PCP during both office and non-office hours - including Telemedicine, non-routine home visits by your 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 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
The types of hospital care services that are eligible for coverage include:
- Room and board charges up to the hospital’s semi-private room rate.
- 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.
- 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.
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.
Skilled-nursing care is covered if MedicallyNec. 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 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
What to do in case of medical emergency on the ExxonMobil Employee Medical Plan - Aetna Select option
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, copays and/or deductibles.
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.
Aetna has adopted the following definition of an emergency medical condition from the Balanced Budget Act (BBA) of 1997:
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
- Serious impairment to bodily function, or
- Serious dysfunction of any bodily organ or part.
Some examples of emergencies are:
- Heart attack or suspected heart attack
- Severe shortness of breath
- Uncontrolled or severe bleeding
- Suspected overdose of medication
- Severe burns
- High fever (especially in infants)
- Loss of consciousness
For both medical and mental health/substance abuse emergencies, whether you are in or out of Aetna’s or Magellan’s service areas respectively, we ask that you follow the guidelines below when you believe you may need emergency care.
- Call your PCP first, if possible (in the case of mental health and substance abuse emergency care participants should call the Magellan telephone number on their ID card as soon as reasonably possible and a clinical care manager will assist with next steps). Your PCP is required to provide urgent care and emergency coverage 24 hours a day, including weekends and holidays. However, if a delay would be detrimental to your health, seek the nearest emergency facility, or dial 911 or your local emergency response service.
- After assessing and stabilizing your condition, the emergency facility should contact your PCP so they can assist the treating physician by supplying information about your medical history.
- If you are admitted to an inpatient facility, notify your PCP as soon as reasonably possible. The emergency room copayment will be waived if you are admitted to the hospital.
- All follow-up care must be coordinated by your PCP.
- If you go to an emergency facility for treatment that Aetna determines is non-emergency in nature, you will be responsible for the bill. The Plan does not cover non-emergency use of the emergency room.
Follow-up care after emergencies
All follow-up care should be coordinated by your PCP. You must have a referral from your PCP and approval from Aetna to receive follow-up care from a nonparticipating provider. Whether you were treated inside or outside your Aetna service area, you must obtain a referral before any follow-up care can be covered. Suture removal, cast removal, X-rays, and clinic and emergency room revisits are some examples of follow-up 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 your PCP.
Some examples of urgent medical conditions are:
- Severe vomiting,
- Sore throat, or
Follow-up care provided by your PCP is covered, subject to the office visit copayment. Other follow-up care by participating specialists is fully covered with a prior written or electronic referral from your PCP, subject to the specialist copay shown in the Benefits schedule. If you are in your service area, you must use a participating urgent care center.
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
If a participant goes to a hospital emergency room for a medical emergency, any medical provider can be utilized (Aetna preferred or non-preferred) and the emergency room copay will apply.
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.
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 when authorized by Magellan.
Fertility services will be covered, when services are authorized by Progyny, the Plan’s designated Fertility Services Network Organization.
Your coverage includes:
Highlights of Your Progyny Benefit
Smart Cycles per family (employee and dependents)
Initial consultations per year
Fertility preservation and Tissue storage
Egg and sperm freezing coverage
Tissue storage is included in applicable treatment cycles for the first year. The Plan covers an additional 1 year of storage
*You have access to an additional Smart Cycle if your first two are not successful
To learn more and activate your benefit, contact Progyny at 1-833-851-2229 to initiate services.
Note: Note: Claims related to diagnosis and treatment of the underlying conditions during your treatment will Progyny will continue to be filed through Aetna
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 instance 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
The mother could be discharged earlier. If so, the plan will pay for 1 post-delivery visit by a health care provider.
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.
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
- Other outpatient diagnostic imaging service where the billed charge exceeds $500
Complex imaging for preoperative testing is covered under this benefit.
Diagnostic lab work and radiological services
Eligible health services include diagnostic radiological services (other than diagnostic complex imaging), lab services, and pathology and other tests, but only when you get them from a licensed radiological facility or lab.
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.
Ordered by a physician for treatment of dysphagia or hypotonia. Oral-motor therapy ordered by a physician for treatment of dysphagia, hypotonia and/or other diagnoses 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
- Radioactive isotopes
Specialty medications, including injectables and infusions for rheumatoid arthritis and other inflammatory conditions, require special handling and may be administered in a hospital, clinic, doctor’s office, or in your home. Some specialty medications, like most oncology drugs administered in a hospital setting, are covered under the medical benefit administered by Aetna. Other specialty medications are covered under the prescription drug program administered by Express Scripts. If you have questions about starting a specialty medication, call Aetna member services and ask to speak to a Health Advocate nurse.
Specialty medications administered by Express Scripts are filled through their specialty pharmacy, Accredo, and can be delivered to hospitals, clinics, doctor’s offices, or to a home health care provider.
Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, you will be responsible for the higher copayment.
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 25th 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.
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.)
Eligible health services include the treatment by the use of acupuncture (manual or electroacupuncture) provided by your physician, if the service is performed as a form of anesthesia in connection with a covered surgical procedure.
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, up to $1,000 per person per year (benefits paid for acupuncture and supplies billed by a doctor of chiropractic are not included in the $1,000 annual maximum).
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.
Clinical trial therapies (experimental or investigational)
Eligible health services include experimental or investigational drugs, devices, treatments or procedures from a provider under an “approved clinical trial” only when you have cancer or terminal illnesses and all of the following conditions are met:
- Standard therapies have not been effective or are not appropriate.
- We determine based on published, peer-reviewed scientific evidence that you may benefit from the treatment.
An "approved clinical trial" is a clinical trial that meets all of these criteria:
- The FDA has approved the drug, device, treatment, or procedure to be investigated or has granted it investigational new drug (IND) or group c/treatment IND status. This requirement does not apply to procedures and treatments that do not require FDA approval.
- The clinical trial has been approved by an Institutional Review Board that will oversee the investigation.
- The clinical trial is sponsored by the National Cancer Institute (NCI) or similar federal organization.
- The trial conforms to standards of the NCI or other, applicable federal organization.
- The clinical trial takes place at an NCI-designated cancer center or takes place at more than one institution.
- You are treated in accordance with the protocols of that study.
- The clinical trial has been pre-approved by Aetna / Magellan.
Clinical trials (routine patient costs)
Eligible health services include "routine patient costs" incurred by you from a provider in connection with participation in an "approved clinical trial" as a “qualified individual” for cancer or other life-threatening disease or condition, as those terms are defined in the federal Public Health Service Act, Section 2709.
As it applies to in-network coverage, coverage is limited to benefits for routine patient services provided within the network.
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
- 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.
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 MedicallyNec, 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.
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.
Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the purchase price.
- 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