The Plan covers medically necessary and preventive treatment, care and services, that are not otherwise excluded. Except for PCP, Obstetrician/Gynecologist, and emergency services, you must have a prior written or electronic referral submitted to Aetna from your PCP, prior to services being rendered to receive coverage for all services and any necessary follow-up treatment.
The Plan participants have access to a network of participating Primary Care Physicians (PCPs), specialists and hospitals that meet Aetna’s requirements for quality and service. These providers are independent physicians and facilities that are monitored for quality of care, patient satisfaction, cost-effectiveness of treatment, office standards and ongoing training.
Each participant in the Plan must select a Primary Care Physician (PCP) when they enroll. See the The Primary Care Physician section.
The prescription drug program
The Plan offers you three cost-saving ways to buy prescription drugs – at a local participating network pharmacy for short-term prescriptions, through Express Scripts home delivery for long-term prescriptions, and through Accredo home delivery for specialty prescriptions. See the Prescription drug program section.
Mental health and substance abuse care
The Plan provides for mental health and substance abuse care through Magellan's nationwide Mental Health PPO network. All inpatient and intensive outpatient care must be precertified. See the Mental health and substance abuse care section.
Covered and excluded expenses
Network providers file claims for you. You are responsible for ensuring that claims for non-network care are filed. See the Claims section.
Culture of Health and Health Management Programs
Culture of Health is a set of programs and resources to support the overall health of our workforce both at work and at home, including online tools and resources for individual goal setting, a personal health survey, and an annual biometric screening. These tools and resources are available to all eligible employees and family members (age 18 and older) eligible to enroll in the Plan.
Additional integrated Health Management programs are available to participants in the Aetna Select options, to help you manage your health and to assist you in obtaining good health care when care is needed. These programs reflect a commitment by you and the company to good health and quality care. The Health Management tools and resources available to Aetna Select participants include a 24 Hour Nurse Line, Medical and Behavioral Health Advocates, Condition Management Programs, Cancer Care Program, Online Diabetes Prevention Program, Fertility Services Counselling, Musculoskeletal Conditions Support, Expert Medical Opinion Services, and Centers of Excellence.
Health management tools and resources are available to you at no additional cost. However, health care claims (e.g., doctor's fees or facilities charges) are processed according to the Plan’s provisions. See the Culture of Health and Health Management programs section.
Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA)
You and your family members who lose eligibility may continue medical coverage for a limited time under certain circumstances. See Continuation of coverage section.
Administrative and ERISA information
This Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, as amended (ERISA), not state insurance laws. See Administrative and ERISA information.
This is an alphabetized list of words and phrases, with their definitions, used in this SPD. These words are underlined and linked throughout the SPD for easy identification. See Key terms section.
Brief summaries of benefits for the Aetna Select option. See 2022 Benefits summary