The Plan covers medically necessary and preventive treatment, care and services, that are not otherwise excluded.
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 Basic Plan features 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
You and the Plan share costs for covered treatment and services. You pay a fixed copayment for covered items such as a network doctor's office visit and most related lab work. For other types of care, you must first satisfy a deductible before the Plan begins paying. If you meet your annual out-of-pocket limit, the Plan pays 100% of most covered costs for the rest of that calendar year. See the Payments section.
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 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 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 section.
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.