Hospital care for:
y Room, board and general nursing care. The maximum covered room rate will be the most common semiprivate rate. If a semiprivate room is not available at the hospital, the area’s prevailing rate for a semiprivate room will be used to calculate the covered room rate. If a private room is desired, the difference between the private and semiprivate rates will not be a covered expense;
y Intensive care while confined to an Intensive Care Unit; and
y Other medically necessary hospital services and supplies.
Convalescent facility care is covered if the individual is admitted to the facility. Coverage includes:
y Room and board; and general nursing care up to a daily amount equal to the facility’s daily charge for its most common semiprivate rate; and
y Charges for medically necessary services and supplies that are provided by the facility and used while in the facility as a bed patient.
Exception: charges incurred after the 100th day of confinement
in a convalescent facility in any one calendar year will not be covered.
Local professional ambulance service to and from the nearest hospital or a nearest hospital or a convalescent facility where care and treatment can be given.
Transportation to, but not from a hospital equipped to furnish special treatment for an injury or illness with approval from your network manager.
Physicians’ fees for:
y Surgical operations;
y Assisting in surgery when required for medical reasons; and
y Administration of general anesthesia when done by other than the operating surgeon.
Physicians’ fees for nonsurgical medical care.
Hyperalimentation or Total Parenteral Nutrition (TPN). These benefits will be provided for persons recovering from or preparing for surgery. However these benefits will not be paid for a period longer than three months.
Charges for skilled private duty nursing care in a home setting for medical treatment of an injury or illness. Treatment must be provided by a licensed nurse not to exceed eight hours per visit within a 24-hour period or 70 visits per calendar year. For the purposes of this provision, skilled private duty nursing care means services or supplies that are:
y Performed by a licensed nurse to assure the safety of the patient and to achieve the medically desired result;
y Ordered by and included in a plan of treatment established by the physician for the patient;
y Provided for treatment of a homebound patient (homebound means being physically incapable of leaving the home); and
y At an appropriate level of care for the treatment of the injury or illness.
In disputed cases, the network manager reserves the right to make the final determination as to whether services or supplies are skilled private duty nursing care.
Charges for medical supplies made and used only for treatment of illness or injury including, but not limited to:
y Custom formed splints or casts for any part of the legs, arms, shoulders, hips, or back;
y Colostomy sets;
y Specialized surgical dressings or bandages;
y Crutches; and
y Trusses.
Rental fees (that cannot exceed the purchase price) for:
y Manually operated wheelchair or hospital bed;
y Iron lung:
y Kidney dialysis equipment; and
y Other durable therapeutic medical equipment made and used only for treatment of injury or illness.
Charges by licensed medical personnel operating with in the scope of their license for:
y Diagnostic X-rays and laboratory services required for investigation of specific symptoms and/or complaints;
y Physiotherapy;
y Speech therapy to restore or correct impaired function due to:
Accidental injury;
Surgical operation;
Cerebral vascular accident (stroke); or
Congenital defects and birth abnormalities; and
Use of X-rays, radium, and other radioactive substances for treatment.
Oxygen and rental of equipment for its use.
The first pair of eyeglasses or contact lenses prescribed due to a cataract operation (not including a lens transplant).
Drugs and medicines (outpatient) that can be legally obtained only by written prescription of a Physician and that are approved by the U.S. Food and Drug Administration for general use by humans. All outpatient prescription drugs are administered by Express Scripts for participants in the Aetna plan. (For more information, see the end of this section of the SPD and the prescription drug exclusions in “Expenses NOT Covered” on page 34.)
Prescription drugs for birth control measures. This includes birth control pills and contraceptives when purchased at participating pharmacies in the Express Scripts Network. The benefit also includes installed, implanted, or injected contraceptives when administered by physicians.
Reimbursement for this is made by the network manager, not Express Scripts.
The initial purchase of artificial limbs or eyes if the loss is the result of either:
y An accidental injury; or
y A surgical operation.
Charges for the following dental procedures:
y Removal of tumors; and
y Treatment of accidental injury to sound natural teeth, including their replacement due to an accident. Expenses incurred later than one year from the date of the accident are not covered.
Chiropractic Care: Treatment or diagnostic services (but not supplies or appliances) rendered or prescribed by a chiropractor for covered chiropractic care will be limited to a maximum calendar year benefit of $500. Treatments are considered essentially maintenance in nature and are not covered.
TMJ and Related Care: Charges for the surgical and nonsurgical care connected with the detection or correction of jaw joint problems, including, temporomandibular joint (TMJ) and craniomandibular disorders or other conditions of the joints linking the jawbone and skull, including the complex of muscles, nerves, and other tissues related to that joint. Dental work, associated with this care, such as, but not limited to, orthodontics, fixed or removable bridgework/dentures, inlays, onlays, crowns, or equilibrations, whether done for dental or medical reasons, is not covered.
Smoking/Tobacco Use Cessation (nicotine patch/nicotine gum): A lifetime maximum benefit of $600 is provided for covered employees and their eligible covered dependents. Benefits are limited to the physician visit that results in the prescription for the nicotine patch or nicotine gum and the cost for the nicotine patch or nicotine gum. Aetna Group Medical Plan Option benefits are subject to the calendar year deductible and/or copayments. This benefit also covers the cost of over- the-counter nicotine patches and gum when one of the following proofs of purchase is submitted:
y A register receipt that identifies the name of the medication and its cost; or
y A register receipt with the pharmacy’s name as well as a UPC seal and a portion of the box/package containing the product name.
The above smoking cessation benefits are administered by Express Scripts. However, certain physician office visits related to cessation of smoking and tobacco use may be covered under the Copay 500 and Copay 750 Options.
In addition to the above benefits, all employees and their eligible family members may access the Quit for Life™ Program, including:
y Free phone-based treatment with an expert Quit Coach.
y Free nicotine patches or gum mailed directly to your home if it’s right for you.
y Free Quit Guides to help you stay on track. Call 1-877-LIFETRK , option 5 to enroll.
Inpatient, Well-Baby Care: All routine nursery charges for a healthy baby are covered during the mother’s hospital stay.
Blood or blood plasma, when not replaced by donations or blood banks.
Surgical benefits related to mastectomies, in accordance with the Women’s Health and Cancer Rights Act of 1998:
y Reconstruction of the breast on which the mastectomy was performed;
y Surgery and reconstruction of the other breast to provide a symmetrical appearance; and
y Prostheses and physical complications during all stages of the mastectomy.