Out-of-network: Nothing up to our Plan allowance for four smoking cessation counseling sessions per quit attempt and two quit attempts per year.
Nothing up to our Plan allowance for OTC drugs and prescription drugs approved by the FDA to treat tobacco dependence.
Out-of-network: Nothing up to our Plan allowance for four smoking cessation counseling sessions per quit attempt and two quit attempts per year.
Nothing up to our Plan allowance for OTC drugs and prescription drugs approved by the FDA to treat tobacco dependence.
Not covered:
Applied Behavioral Analysis (ABA)
All charges All charges
Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals
Important things you should keep in mind about these benefits:
•
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.•
Your deductible is $1,500 for Self Only and $3,000 for Self and Family enrollment. The Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section. (Note: If you are enrolled in Medicare Part A and B and Medicare is primary, we will waive the deductible).•
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.•
After you have exhausted your Medical Fund and satisfied your deductible, your Traditional Medical Plan begins.•
Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.•
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, etc.).•
YOU OR YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.* Note: If you are covered by Medicare Part A and B and it is primary, your out-of-pocket costs for services that both Medicare Part A or B and we cover depend on whether your provider accepts Medicare assignment for the claim.
- If your provider accepts Medicare assignment, then you pay nothing for covered charges.
- If your provider does not accept Medicare assignment, then you pay the difference between the "limiting charge" or the provider's charge (whichever is less) and our payment
combined with Medicare's payment.
Note: We do not waive benefit limitations. In addition, we do not waive any coinsurance or copayments for prescription drugs.
Benefit Description You pay
(Note: If you are enrolled in Medicare Part A and B and Medicare is primary, we will waive the deductible)
Surgical procedures Aetna Direct Aetna Direct with
Medicare A & B primary*
A comprehensive range of services, such as:
• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
In-network: 20% of our Plan allowance
Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.
In-network: 0% of our Plan allowance
Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.
Surgical procedures - continued on next page 111
2015 Aetna HealthFund® HDHP and Aetna Direct Plan Aetna Direct Section 5(b)
Benefit Description You pay
Surgical procedures (cont.) Aetna Direct Aetna Direct with
Medicare A & B primary*
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery) – a condition that has persisted for at least 2 years in which an individual has a body mass index (BMI) exceeding 40 or a BMI greater than 35 in conjunction with documented significant co-morbid conditions (such as coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea or refractory hypertension).
- Eligible members must be age 18 or over or have completed full growth.
- Members must complete a physician-supervised nutrition and exercise program within the past two years for a cumulative total of six months or longer in duration, with participation in one program for at least three consecutive months, prior to the date of surgery documented in the medical record by an attending physician who supervised the member’s participation; or member participation in an organized
multidisciplinary surgical preparatory regimen of at least three months duration proximate to the time of surgery.
- For members who have a history of severe psychiatric disturbance or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, a pre-operative psychological evaluation and clearance is necessary.
We will consider:
- Open or laparoscopic Roux-en-Y gastric bypass;
or
- Open or laparoscopic biliopancreatic diversion with or without duodenal switch; or
- Sleeve gastrectomy; or
- Laparoscopic adjustable silicone gastric banding (Lap- Band) procedures.
- Insertion of internal prosthetic devices. See 5 (a) – Orthopedic and prosthetic devices for device coverage information
Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done.
For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the
In-network: 20% of our Plan allowance
Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.
In-network: 0% of our Plan allowance
Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.
Benefit Description You pay
Surgical procedures (cont.) Aetna Direct Aetna Direct with
Medicare A & B primary*
• Treatment of burns
• Skin grafting and tissue implants
• Gender reassignment surgery*
- The Plan will provide coverage for the following when the member meets Plan criteria:
• Surgical removal of breasts for female-to-male patients
• Surgical removal of uterus and ovaries in female-to-male and testes in male-to-female
• Reconstruction of external genitalia**
* Subject to medical necessity
** Note: Requires Precertification. See “Services requiring our prior approval” on pages 23-24. You are responsible for ensuring that we are asked to
precertify your care; you should always ask your physician or hospital whether they have contacted us.
For precertification or criteria subject to medical necessity, please contact us at 1-888/238-6240.
In-network: 20% of our Plan allowance
Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.
In-network: 0% of our Plan allowance
Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.
Not covered:
• Reversal of voluntary surgically-induced sterilization
• Surgery primarily for cosmetic purposes
• Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
• Routine treatment of conditions of the foot; see Foot care
• Gender reassignment services that are not considered medically necessary
All charges All charges
Reconstructive surgery Aetna Direct Aetna Direct with
Medicare A & B primary*
• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
- the condition produced a major effect on the member’s appearance and
- the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital and developmental anomalies are cleft lip, cleft palate, webbed fingers, and webbed toes. All surgical requests must be preauthorized.
In-network: 20% of our Plan allowance
Out-of-network: 40% of our Plan allowance and any difference between our allowance and the billed amount.
In-network: 0% of our Plan allowance
Out-of-network: 0% of our Plan allowance and any difference between our allowance and the billed amount.
Reconstructive surgery - continued on next page 113
2015 Aetna HealthFund® HDHP and Aetna Direct Plan Aetna Direct Section 5(b)