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%. 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% (for either network or non-network providers) include the following:
Routine physical exams
Eligible health services include office visits to your physician or other health professional for routine physical exams.
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 physician, PCP, obstetrician (OB), gynecologist (GYN) or OB/GYN. This includes pap smears. 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 health professional 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
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 physician's, OB's, GYN's, or OB/GYN’s office. Services are only paid at 100% if network providers are used.
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, 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.
Lactation support, Breastfeeding durable medical equipment and contraceptive services are covered at 100% only through in-network providers.
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.
Physicians and other health professionals
Physician services include: non-routine office visits with your physician, such as your primary care physician, during both office and non-office hours - including Telemedicine, non-routine home visits, treatment for illness and injury and injections, including routine allergy desensitization injections in your physician´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 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 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
In case of a medical emergency
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.
If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. Aetna has adopted the following definition of an emergency medical condition:
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.
- Uncontrolled or severe bleeding.
- Suspected overdose of medication.
- Severe burns.
- High fever (especially in infants).
- Loss of consciousness.
- Some common examples of non-emergencies are:
- Routine exams and immunizations.
- Ear Infections.
- Colds and Flu.
Reimbursement for emergency services
Reimbursement for emergency services from non-network providers are limited to reasonable and customary amounts, including professional fees for radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, intensivists, ambulance, or emergency room physician services. In most instances, the provider will accept this reimbursement; however in the event you are billed for any balance, you may submit the balance to Aetna for additional processing. If you do so and you are enrolled in the automatic rollover process to the Health Care Flexible Spending Account (HCFSA), an overpayment from the HCFSA may result, and you should contact Aetna to discuss options to return the overpaid HCFSA funds back into the account.
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 the Benefit summary.
Reimbursement for non-emergency services
If you go to a non-network emergency room and your condition is determined to be non-emergency, then the expense may be subject to the non-network level of reimbursement (either 60% for the POS II B or 55% for the POS II A), after the plan year deductible has been satisfied
In case of an urgent condition
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 copay, equal to the specialist physician copay 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 Medical POS II network provider, choose Find a Doctor on Aetna 's website (www.aetna.com) or launch the Aetna mobile app.
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, choose Find a Doctor on Aetna’s member website (www.aetna.com), or launch the Aetna mobile app 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.
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.
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.
Eligible health services include obesity surgery, which is also known as “weight loss surgery.” Obesity surgery is a type of procedure performed on people who are morbidly obese, for the purpose of losing weight. Obesity is typically diagnosed based on your body mass index (BMI). To determine whether you qualify for obesity surgery, your doctor will consider your BMI and any other condition or conditions you may have. In general, obesity surgery will not be approved for any member with a BMI less than 35.
Your doctor will request approval in advance of your obesity surgery. The plan will cover charges made by a network provider for the following outpatient weight management services:
- An initial medical history and physical exam
- Diagnostic tests given or ordered during the first exam
- Outpatient prescription drug benefits included under the Outpatient prescription drugs section
Health care services include one obesity surgical procedure. However, eligible health services also include a multi-stage procedure when planned and approved by the plan. Your health care services include adjustments after an approved lap band procedure. This includes approved adjustments in an office or outpatient setting.
You may go to any of our network facilities that perform obesity surgeries.
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
- Oral surgery and related procedures covered under the POS II plan are reimbursed at 75% for the POS II A and 80% for the POS II B, regardless of the provider’s network participation.
- Treatment of temporomandibular disorders, sometimes referred to as TMJ/TMD, including splints and orthotics, when preauthorized by Aetna. This includes diagnosis and surgical treatment of the jaw and cranio-mandibular joint resulting from an accident, trauma, congenital or developmental defect, or pathology.
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
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.
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.
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 prescription drugs
Eligible health services include specialty prescription drugs when they are:
- Purchased by your provider, and
- Injected or infused by your provider in an outpatient setting such as:
- A free-standing outpatient facility
- The outpatient department of a hospital
- A physician in the office
- A home care provider in your home
- And, listed on our specialty prescription drug list as covered under this booklet.
You can access the list of specialty prescription drugs by contacting Member Services by logging onto your Aetna secure member website at www.aetna.com or calling the number on your ID card to determine if coverage is under the outpatient prescription drug benefit or this booklet.
When injectable or infused services and supplies are provided in your home, they will not count toward any applicable home health care maximums.
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 procedure, or
- 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.
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. (See Speech Therapy under Exclusions. 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.
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 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.
Hearing aids and exams
Benefits are provided up to a maximum of $2,500 after the deductible and coinsurance are paid for one or more hearing aids every rolling five year period, which also includes the repair of a hearing aid. However, shipping and handling charges and routine maintenance such as battery replacement are not covered. The amount allowed is subject to reasonable and customary limits but not negotiated rates. There are no Medical POS II preferred providers for hearing aids and related materials. The member will be responsible for the difference between the billed and allowable amount regardless of provider participation.
You may be able to maximize your benefit through the Amplifon Hearing Health Care (formerly HearPo) or the Hearing Care Solutions Discount Program. These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of-pocket expenses could be lower. To find a participating hearing discount center location, visit www.aetna.com and select "Hearing Discount Locations". To compare costs, please call Amplifon Hearing Health Care at 1-877-301-0840 or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.
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