Important
Disclosure
Information
Aetna Advantage Plans for
Individuals and Families
13.28.301.1 (5/06)
This healthcare coverage may not
cover all your healthcare expenses.
Read your coverage documents
carefully to determine which healthcare
services are covered. To contact the
plan if you are a member, call the
number on your ID card; all others,
call 1-800-230-1483.
Plan of Benefits
Your covered benefits are underwritten by Aetna Life
Insurance Company, 151 Farmington Avenue,
Hartford, CT 06156. The benefits and main characteristics of your health plan will be set forth in the
Certificate of Coverage and the Summary of Coverage
that you will be receiving at a later date.
Covered services include numerous types of treatment
provided by physicians, specialists and hospitals.
However, in order to be covered, all services, including
the location (type of facility), duration and costs of services, must be medically necessary as defined below
and as determined by Aetna.** Your health plan will
also exclude and/or limit coverage for several services
and treatments, including but not limited to, cosmetic
surgery and any experimental procedure.
The information that follows provides general information regarding your health plan. For a complete
description of the benefits available to you, including
procedures, exclusions and limitations, refer to your
specific plan documents, which may include the Policy,
Joinder Agreement, Certificate of Coverage, and any
applicable riders and amendments to your plan.
Cost Sharing
You are responsible for any copayments, coinsurance
and deductibles for covered services rendered to yourself or any member of your family covered under the
health plan. These obligations are paid directly to the
provider or facility at the time the service is rendered.
Copayment, coinsurance and deductible amounts are
listed in your benefits summary and plan documents.
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Emergency Care
If you need emergency care, you are covered 24 hours
a day, 7 days a week,. An emergency medical condition is one manifesting itself by acute symptoms of
sufficient severity such that a prudent layperson, who
possesses average knowledge of health and medicine,
could reasonably expect the absence of immediate
medical attention to result in serious jeopardy to the
person’s health, or with respect to a pregnant woman,
the health of the woman and her unborn child.
Whether you are in or out of an Aetna service area,
we simply ask that you follow the guidelines below
when you believe you need emergency care.
■
Call the local emergency hotline (ex. 911) or go
to the nearest emergency facility. If a delay
would not be detrimental to your health, call
your physician. Notify your physician as soon as
possible after receiving treatment.
■
If you are admitted to an inpatient facility, you or
a family member or friend on your behalf should
notify Aetna as soon as possible.
Prescription Drugs
The following applies if your plan provides outpatient
prescription drug coverage through an Aetna pharmacy network. Pharmacies are reimbursed based upon a
combination of the following payment methodologies:
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■
Discount from Average Wholesale Price: Pharmacy
receives an agreed upon percentage discount from
the Average Wholesale Price of the pharmaceutical
product dispensed.
■
Fee Schedule: Pharmacy is paid a fee established by
Aetna for each pharmaceutical product dispensed.
■
Professional Dispensing Fee: Pharmacy is paid a
professional fee as agreed upon by Pharmacy and
Aetna for each pharmaceutical product dispensed.
If your plan covers outpatient prescription drugs, your
plan may include a preferred drug list (also known as
a “drug formulary”). The preferred drug list includes
a list of prescription drugs that, depending on your
prescription drug benefits plan, are covered on a
preferred basis. Many drugs, including many of those
listed on the preferred drug list, are subject to rebate
arrangements between Aetna and the manufacturer
of the drugs. Such rebates are not reflected in and do
not reduce the amount a member pays for a prescription
drug. In addition, in circumstances where your
prescription plan utilizes copayments or coinsurance
calculated on a percentage basis or a deductible, your
costs may be higher for a preferred drug than they
would be for a non-preferred drug. For information
regarding how medications are reviewed and selected
for the preferred drug list, please refer to Aetna’s
website at www.aetna.com or the Aetna Preferred
Drug (Formulary) Guide. Printed Preferred Drug Guide
information will be provided, upon request or if applicable, annually for current members and upon enrollment for new members. Additional information can
be obtained by calling Member Services at the tollfree number listed on your member ID card. The medications listed on the preferred drug list are subject to
change in accordance with applicable state law.
Your prescription drug benefit is generally not limited
to drugs listed on the preferred drug list. Medications
that are not listed on the preferred drug list (non-preferred
or nonformulary drugs) may be covered subject to the
limits and exclusions set forth in your plan documents.
Covered nonformulary prescription drugs may be
subject to higher copayments or coinsurance under
some benefit plans. Some prescription drug benefit
plans may exclude from coverage certain nonformulary
drugs that are not listed on the preferred drug list. If
it is medically necessary for members enrolled in these
benefit plans to use such drugs, their physicians (or
pharmacist in the case of antibiotics and analgesics)
may contact Aetna to request coverage as a medical
exception. Check your plan documents for details.
In addition, certain drugs may require precertification
or step-therapy before they will be covered under
some prescription drug benefit plans. Step-therapy is a
different form of precertification which requires a trial
of one or more “prerequisite therapy” medications
before a “step-therapy” medication will be covered.
If it is medically necessary for a member to use a
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medication subject to these requirements, the member’s physician can request coverage of such drug as a
medical exception. In addition, some benefit plans
include a mandatory generic drug cost-sharing requirement. In these plans, you may be required to pay the
difference in cost between a covered brand-name drug
and its generic equivalent in addition to your copayment if you obtain the brand-name drug. Non-prescription drugs and drugs in the Limitations and
Exclusions section of the plan documents (received
and/or available upon enrollment) are not covered, and
medical exceptions are not available for them.
Depending on the plan selected, new prescription
drugs not yet reviewed for possible addition to the
preferred drug list are either available at the highest
copay under plans with an “open” formulary, or
excluded from coverage unless a medical exception is
obtained under plans that use a “closed” formulary.
These new drugs may also be subject to precertification or step-therapy.
Members should consult with their treating physicians
regarding questions about specific medications. Refer
to your plan documents or contact Member Services
for information regarding terms and conditions limitations of coverage.
If you use the mail order prescription program of
Aetna Rx Home Delivery, LLC, you will be acquiring
these prescriptions through an affiliate of Aetna.
Aetna’s negotiated charge with Aetna Rx Home
Delivery® may be higher than Aetna Rx Home
Delivery’s cost of purchasing drugs and providing
mail-order pharmacy services. For these purposes,
Aetna Rx Home Delivery’s cost of purchasing drugs
takes into account discounts, credits and other
amounts that it may receive from wholesalers,
manufacturers, suppliers and distributors.
If you use the Aetna Specialty Pharmacy specialty drug
program, you will be acquiring these prescriptions
through Aetna Specialty Pharmacy, LLC, which is
jointly owned by Aetna and Priority Healthcare, Inc.
Aetna’s negotiated charge with Aetna Specialty
Pharmacy may be higher than Aetna Specialty
Pharmacy’s cost of purchasing drugs and providing
specialty pharmacy services. For these purposes, Aetna
Specialty Pharmacy’s cost of purchasing drugs takes
into account discounts, credits and other amounts
that it may receive from wholesalers, manufacturers,
suppliers and distributors.
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How Aetna Compensates Your Physician and
Other Providers
All the physicians in the directory are independent
practicing physicians that are neither employed
nor exclusively contracted with Aetna. Individual
physicians are in the network by either directly
contracting with Aetna and/or affiliating with a
group or organization that contracts with us.
Participating physicians, hospitals and other providers
in our network are compensated in various ways for
the services covered under your plan.
■
Per individual service or case (fee for service at
contracted rates).
■
Per hospital day (per diem contracted rates).
You are encouraged to ask your physicians and other
providers how they are compensated for their services.
Claims Payment for Nonparticipating Providers
and Use of Claims Software
If your plan provides coverage for services rendered by
non-participating providers, you should be aware that
Aetna determines the usual, customary and reasonable fee for a provider by referring to commercially
available data reflecting the customary amount paid
to most providers for a given service in that geographic
area or by accessing other contractual arrangements.
If such data is not commercially available, our determination may be based upon our own data or other
sources. Aetna may also use computer software and
other tools to take into account factors such as the
complexity, amount of time needed and manner of
billing. You may be responsible for any charges Aetna
determines are not covered under your plan.
Clinical Policy Bulletins
Aetna’s Clinical Policy Bulletins (CPBs) describe Aetna’s
policy determinations of whether certain services or
supplies are medically necessary, based upon a review
of currently available clinical information. Clinical
determinations in connection with individual coverage
decisions are made on a case-by-case basis consistent
with applicable policies.
Aetna’s Clinical Policy Bulletins (CPBs) do not constitute
medical advice. Treating providers are solely responsible
for medical advice and treatment of members.
Members should discuss any CPB related to their
coverage or condition with their treating provider.
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While Aetna’s Clinical Policy Bulletins (CPBs) are
developed to assist in administering plan benefits,
they do not constitute a description of plan benefits.
Each benefit plan defines which services are covered,
which are excluded and which are subject to dollar
caps or other limits. Members and their providers
will need to consult the member’s benefit plan to
determine if there are any exclusions or other benefit
limitations applicable to this service or supply.
Clinical Policy Bulletins (CPBs) are regularly updated
and are therefore subject to change. Aetna’s Clinical
Policy Bulletins are available online at
www.aetna.com.
Certification and Necessary Services
Certification is the process of collecting information
prior to inpatient admissions and performance of
selected ambulatory procedures and services. The
process permits advance eligibility verification,
determination of coverage and communication
with the physician and/or you. It also allows Aetna to
coordinate the patient’s transition from the inpatient
setting to the next level of care (discharge planning),
or to register patients for specialized programs like
disease management, case management or our
prenatal program. In some instances, precertification
is used to inform physicians, you and other health
care providers about cost-effective programs and
alternative therapies and treatments.
Certain health care services, such as hospitalization
or outpatient surgery, require certification with Aetna
to ensure coverage for those services. When you are
to obtain services requiring certification through a participating provider, this provider should certify those
services prior to treatment. If your plan covers out-ofnetwork benefits and you may self-refer for covered
services, it is your responsibility to contact Aetna to
certify those services which require certification.
You must obtain certification for certain types of
care rendered by non-preferred providers to avoid a
reduction in benefits paid for that care. Refer to your
plan documents for specific information.
Only necessary services are covered. A service or
supply furnished by a particular provider is necessary
if Aetna determines that it is appropriate for the
diagnosis, the care or the treatment of the disease
or injury involved.
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To be appropriate, the service or supply must:
■ be care or treatment, as likely to produce a significant
positive outcome as and no more likely to produce
a negative outcome than any alternative service or
supply, both as to the disease or injury involved and
the person’s overall health condition;
■
be a diagnostic procedure, indicated by the health
status of the person, and be as likely to result in
information that could affect the course of treatment as and no more likely to produce a negative
outcome than any alternative service or supply, both
as to the disease or injury involved and the person’s
overall health condition; and
■
as to diagnosis, care and treatment, be no more
costly (taking into account all health expenses
incurred in connection with the service or supply)
than any alternative service or supply to meet the
above tests.
In determining if a service or supply is
appropriate under the circumstances, Aetna
will consider the following:
■
information provided on the affected person’s
health status;
■
reports in peer-reviewed medical literature;
■
reports and guidelines published by nationally
recognized healthcare organizations that include
supporting scientific data;
■
generally recognized professional standards of
safety and effectiveness in the United States for
diagnosis, care or treatment;
■
the opinion of health professionals in the generally
recognized health specialty involved; and
■
any other relevant information brought to
Aetna’s attention.
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In no event will the following services or supplies
be considered to be necessary:
■
those that do not require the technical skills of a
medical, a mental health or a dental professional; or
■
those furnished mainly for the personal comfort
or convenience of the person, any person who
cares for him or her, any person who is part of his
or her family, any healthcare provider or healthcare
facility; or
■
those furnished solely because the person is an
inpatient on any day on which the person’s disease
or injury could safely and adequately be diagnosed
or treated while not confined; or
■
those furnished solely because of the setting if the
service or supply could safely and adequately be
furnished in a physician’s or a dentist’s office or
other less costly setting.
To request certification, you must call the number
shown on your ID card. Such certification must be
obtained before care is received or in the case of an
emergency admission, procedure or treatment, within
48 hours after the start of confinement as a full-time
inpatient or the performance of the procedure or
treatment (72 hours if the confinement starts, or if
the procedure or treatment is performed on a Friday
or Saturday) or as soon as reasonably possible.
Utilization Review/Patient Management
Aetna has developed a patient management program
to assist in determining what health care services are
covered under the health plan and the extent of such
coverage. The program assists members in receiving
appropriate healthcare and maximizing coverage for
those healthcare services.
Where such use is appropriate, our utilization review/
patient management staff uses nationally recognized
guidelines and resources, such as The Milliman Care
Guidelines® to guide the precertification, concurrent
review and retrospective review processes. To the
extent certain utilization review/patient management
functions are delegated to integrated delivery systems,
independent practice associations or other provider
groups (“Delegates”), such Delegates utilize criteria
that they deem appropriate. Utilization review/patient
management polices may be modified to comply with
applicable state law.
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Only medical directors make decisions denying
coverage for services for reasons of medical
necessity. Coverage denial letters for such decisions
delineate any unmet criteria, standards and
guidelines, and inform the provider and member
of the appeal process.
Concurrent Review
The concurrent review process assesses the necessity
for continued stay, level of care and quality of care
for members receiving inpatient services. All inpatient
services extending beyond the initial certification
period will require Concurrent Review.
Discharge Planning
Discharge planning may be initiated at any stage
of the patient management process and begins
immediately upon identification of post-discharge
needs during precertification or concurrent review.
The discharge plan may include initiation of a variety
of services/ benefits to be utilized by the member
upon discharge from an inpatient stay.
Retrospective Record Review
The purpose of retrospective review is to retrospectively
analyze potential quality and utilization issues, initiate
appropriate follow-up action based on quality or
utilization issues, and review all appeals of inpatient
concurrent review decisions for coverage of healthcare
services. Aetna’s effort to manage the services
provided to members includes the retrospective
review of claims submitted for payment, and of
medical records submitted for potential quality and
utilization concerns.
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Complaints, Appeals and
External Review
This Complaint Appeal and External Review Process
may not apply in your state. If you have any questions
contact member services at the number on your ID.
Filing a Complaint or Appeal
Aetna is committed to addressing members’ coverage
issues, complaints and problems. If you have a
coverage issue or other problem, call Member Services
at the toll-free number on your ID card. You can also
contact Member Services through the Internet at:
www.aetna.com. If Member Services is unable to
resolve your issue to your satisfaction, it will be forwarded to the appropriate department for handling.
If you are dissatisfied with the outcome of your initial
contact, you may file an appeal. If you are not
satisfied after filing a formal appeal, you may request
a second level appeal of the decision. Your appeal
will be decided in accordance with the procedures
applicable to your plan and applicable state law.
Refer to your plan documents for further details
regarding your plan’s appeal procedure.
Confidentiality and Privacy Notices
Aetna considers personal information to be confidential and has policies and procedures in place to protect
it against unlawful use and disclosure. By “personal
information,” we mean information that relates to a
member’s physical or mental health or condition, the
provision of health care to the member or payment
for the provision of health care to the member.
Personal information does not include publicly
available information or information that is available
or reported in a summarized or aggregate fashion
but does not identify the member.
When necessary or appropriate for your care or
treatment, the operation of our health plans, or other
related activities, we use personal information
internally, share it with our affiliates, and disclose it to
health care providers (doctors, dentists, pharmacies,
hospitals and other caregivers), payors (health care
provider organizations and others who may be
financially responsible for payment for the services or
benefits you receive under your plan), other insurers,
third-party administrators, vendors, consultants,
government authorities, and their respective agents.
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These parties are required to keep personal
information confidential as provided by applicable law.
Participating network providers are also required to
give you access to your medical records within a
reasonable amount of time after you make a request.
Some of the ways in which personal information is
used include claims payment; utilization review and
management; medical necessity reviews; coordination
of care and benefits; preventive health, early detection,
and disease and case management; quality assessment
and improvement activities; auditing and antifraud
activities; performance measurement and outcomes
assessment; health claims analysis and reporting;
health services research; data and information systems
management; compliance with legal and regulatory
requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from
other insurers; underwriting activities; and due diligence
activities in connection with the purchase or sale of
some or all of our business. We consider these activities key for the operation of our health plans. To the
extent permitted by law, we use and disclose personal
information as provided above without member consent. However, we recognize that many members do
not want to receive unsolicited marketing materials
unrelated to their health benefits. We do not disclose
personal information for these marketing purposes
unless the member consents. We also have policies
addressing circumstances in which members are
unable to give consent.
To obtain a printed copy of our Notice of Privacy
Practices, which describes in greater detail our
practices concerning use and disclosure of personal
information, please write to Aetna’s Legal Support
Services Department at 151 Farmington Avenue,
W121, Hartford, CT 06156. You can also visit our
Internet site at www.aetna.com. You can link
directly to the Notice of Privacy Practices by selecting
the “Privacy Notices” link at the bottom of the page.
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Notice to Members
While this information is believed to be accurate as of
the print date, it is subject to change.
This material is for informational purposes only and
is neither an offer of coverage nor medical advice. It
contains only a partial, general description of plan
benefits or programs and does not constitute a contract. Aetna arranges for the provision of health care
services. However, Aetna itself is not a provider of
health care services and therefore, cannot guarantee
any results or outcomes. Consult the plan documents
[Policy and Certificate of Coverage or, under the
Trust, your Joinder Agreement and your Certificate
of Coverage] to determine governing contractual
provisions, including procedures, exclusions and
limitations relating to the plan. The availability of a
plan or program may vary by geographic service area
and by plan design. These plans contain exclusions
and some benefits are subject to limitations or visit
maximums.
With the exception of Aetna Rx Home Delivery®, all
participating physicians, hospitals and other health
care providers are independent contractors and are
neither agents nor employees of Aetna. Aetna Rx
Home Delivery, LLC. Is a subsidiary of Aetna Inc.
The availability of any particular provider cannot be
guaranteed, and provider network composition is
subject to change. Notice of the change shall be
provided in accordance with applicable state law.
Certain primary care physicians are affiliated with
integrated delivery systems or other provider groups
(such as independent practice associations and
physician-hospital organizations), and members who
select these providers will generally be referred to
specialists and hospitals within those systems or
groups. However, if a system or group does not
include a provider qualified to meet a member’s
medical needs, a member may request to have
services provided by non-system or non-group
providers. A member’s request will be reviewed and
will require prior authorization from the system or
group and/or Aetna to be a covered benefit.
For up-to-date information, please visit our DocFind®
online provider directory at www.aetna.com.
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Aetna is the brand name used for products and services
provided by one or more of the Aetna group of
subsidiary companies. The company that underwrites
benefits coverage is Aetna Life Insurance Company
and/or Aetna Life Insurance Company through an out-ofstate Blanket Trust arrangement.
If you need this material translated into another language,
please call Member Services at 1-888-982-3862.
Si usted necesita este documento en otro idioma, por favor
llame a Servicios al Miembro al 1-888-982-3862.
13.28.301.1(5/06)
©2006 Aetna Inc.
